LIBRARY OF CONGRESS. 



Chap. Copyright No. 

Shelf ."T^E^^Yq 



UNITED STATES OF AMERICA. 



Rhinology 



Laryngology and Otology 



SIGNIFICANCE IN GENERAL MEDICINE 



BY 

E, P* FRIEDRICH, M,D. 

PRIVATDOCENT AT THE UNIVERSITY OF LEIPZIG 



Butborl3eD translation from tbe ©erman 



H. HOLBROOK CURTIS, M,D. 

CONSULTING SURGEON TO THE NEW YORK NOSE AND THROAT HOSPITAL 
AND TO THE DIPHTHERIA AND SCARLET FEVER HOSPITALS 



PHILADELPHIA AND LONDON 

W, B. SAUNDERS «& COMPANY 

1900 




47545 



l-ibrkit y of Co»im»"««s 

SEP 15 1900 

Cofyri|*« •"try 

SECONO COPV. 
ORDtR DtVISION, 

SEP 20 I9UU 






,^ 



800/ 2 

Copyright, igoo, by W. B. Saunders & CoMPA^ 



EDITOR'S PREFACE 



At the present time, when it is the fashion for almost every 
specialist to pad his individual work and announce a book 
on the ear, nose, and throat, — which upon perusal is gener- 
ally found to cover ground already occupied, — it is certainly 
with pardonable enthusiasm that we greet a masterly treatise 
of a thoroughly original type, the intrinsic worth of which 
warrants its appearance in our own language. Friedrich 
has realized that the general practitioner must acquaint 
himself with the rapid advances in the modern teaching of 
otolaryngology, and he has constructed a book so rich in 
statistics and reference, so learned in its argumentative 
deductions, and at the same time so convincing in the man- 
ner of conservative presentation, that no specialist can afford 
to neglect the opportunity of acquainting himself with the 
subject-matter of his work. The results of the vast clin- 
ical experience of the author, the detailed reports, and the 
extensive bibliography make the volume valuable alike to 
the specialist and the general practioner. 

Far too little attention has been paid in the past to early 
symptomatic manifestations in the respiratory tract ; nor 
has sufficient study been given to the reflex neuroses of the 
ear and air-passages and their diagnostic significance. 

One can not read the book without admiration for a 
physician who is able at once to be observant of the 
minutest detail of constitutional disturbance, and also to 
possess so intimate a knowledge of the specialties whose 
reciprocal relations he so ably defines. 

The chapters treating of nervous diseases are most inter- 
esting and rich in new material, as are also those upon 
the exanthemata and their sequels. 

In the translation there has been no effort made to ren- 
der into elegant English the characteristic construction of 
the German text. To preserve the exact meaning of the 
5 



O EDITOR S PREFACE. 

author and his individual style of expression has been our 
aim, and the work is reproduced from a strictly scientific 
point of view. 

The attention which has been given to the morbid anat- 
omy and pathology is exceptional, and the book as a whole 
ranks among the most progressive works of to-day. 

The editor has no hesitation in indorsing the book as the 
best treatise upon the relationship of general diseases to 
those of the ear, nose, and throat that has appeared up to 
this time. 

H. HoLBROOK Curtis. 

iiS ]\Ia<iison Avenue, New York City. 



PREFACE 



In these days of specialism there is a laudable tendency 
to tighten the bonds that unite the daughter to the mother 
science. On every hand we see the publication of works 
destined to show the correlation between various branches 
of medicine, and to awaken the interest of representatives 
of the various specialties for one another's work by defining 
the lines where their respective provinces meet. 

The present book belongs to this category, and the 
author's object has been to point out the interdependence 
between diseases of the entire organism and diseases of the 
nose, pharynx, larynx, and ears. 

It is a somewhat hazardous experiment, this attempt to 
unite the three specialties rhinology, laryngology, and 
otology in a single treatise, and I am well aware of the 
opposition it is destined to meet from the extreme advocates 
of specialism. But let us examine the relation between 
these three specialties. A study of the history shows us 
that rhinology was added to laryngology in response to 
a practical demand, and that recent developments have 
shown that otology stands more and more in need of rhi- 
nology — so much so that a distinction might be made be- 
tween rhino-laryngology and rhino-otology. But we ought 
rather to oppose this subdivision, since the study of rhi- 
nology is as important for the successful practice of laryn- 
gology, as a knowledge of nasal affections is indispensable 
in the practice of otology ; in other words, one specialty 
encroaches on the domain of another, and it is impossible 
to establish definite boundaries. 

Whenever it becomes necessar>' to examine more care- 
fully certain regions of the body, anatomically and physi- 
ologically distinct, the natural result is the growth of a 
specialty. 

As experience shows that certain portions of the organism 



5 PREFACE. 

which, owing to their position and function, can not be 
reached by ordinary methods of examination practised in 
general medicine, demand the development of special 
methods to enable us to examine new regions both in the 
healthy and in the diseased state, and as with the growth 
of our knowledge additional facts are discovered, the field 
gradually widens, and new departments spring into exist- 
ence, which are only too often regarded by both physicians 
and laymen as isolated domains of the general science. 

There must, of course, be a period in the development 
of a specialty during which those who practise it devote 
their entire energy to the study of the anatomy and 
physiology of the new regions, and to the creation of a 
special pathology and method of treatment adapted to the 
peculiarities of the parts concerned. Once this foundation 
is established, however, it becomes important to incorporate 
the new discoveries in the scheme of general medicine. 
A specialty should not be regarded as a thing apart and a 
kind of appendage ; it should take an active part in all the 
problems with the solution of which general medicine is 
concerned. To do this an active cooperation between 
general medicine and every one of the various specialties is 
indispensable. Whenever it is lacking, the specialty is in 
danger of becoming a mere source of revenue and of losing 
its scientific significance ; while, on the other hand, the 
general practitioner will fail to recognize special symptoms 
which might have been of the greatest importance to him 
in the recognition and treatment of his cases. 

In taking this standpoint and in describing the relations 
which manifest themselves as disturbances of the general 
organism in disease of special parts, or as disturbances of 
special parts in general disease, I lay no claim to origin- 
ality, for several works on our specialties have appeared 
with a special reference to general medicine. Moritz- 
Schmidt, in his excellent book on " Diseases of the Upper 
Air-passages," has followed the same Hues, "writing from 
practice for practice" ; Lori discusses "Alterations of the 
Pharynx, Larynx, and Trachea due to Other Diseases " ; 
while Moos and Haug discuss " The Diseases of the Ear 
in their Relation to General Diseases," one in his chapter 
on the Etiology of the Diseases of the Ear in Schwartze's 
" Handbuch der Otologic," the other in a special mono- 
graph. 



My undertaking a new work on this theme merely shows 
the abundance of material accumulated during the last few 
years, and the development of new points of view that 
justify the publication of another book on the subject. It 
has been my endeavor to confine myself to the positive, 
and, disregarding speculation, to present to the reader 
nothing but exact and well-established information. 

The treatment of the subject is purposely succinct, 
especially the description of the commoner diseases. A 
detailed description of special symptomatology is not 
within the scope of this book, which does not pretend to 
be a special text-book in the ordinary sense, being intended 
to awaken the interests of both the general practitioner 
and the speciaUst in certain matters which appear to me to 
demand special attention and further elaboration. As I 
have drawn freely from the entire literature, bibliographic 
notes seemed to me indispensable. They do not pretend 
to anything like completeness, but I have, I hope, cited the 
most important works, a reference to which will enable the 
reader to elucidate any doubtful questions that may present 
themselves. 

E. P. Friedrich. 



CONTENTS. 



I. DISEASES OF THE RESPIRATORY ORGANS. 

PAGE 

General Remarks on the Relations Existing between the Nose, 

Pharynx, and Larynx 17 

Relations Existing between the Nose, Pharynx, Larynx, and Lungs . 19 
Significance of the Upper Air-passages in the Physiology of 

Breathing 19 

Diseases of the Lungs Due to Disturbances- of the Physiologic 

Function of the Upper Air-passages 26 

Diseases of the Lungs in Morbid Conditions of the Upper Air- 
passages 28 

Alterations in the Upper Air-passages in Diseases of the Lungs . 31 
Alterations in the Upper Air-passages in Diseases of the Medi- 
astinum ;^^ 

Relations between the Upper Air-passages and the Ears 35 

The Effect of Disturbances of the Normal Function of the Eu- 
stachian Tube 36 

Disturbances of the Function of the Eustachian Tube Due to 

Alterations in the Upper Air-passages 40 

Diseases of the Middle Ear Due to Infection from the Post-nasal 

Space 43 

The Effect of Various Diseases of the Respiratory Organs on the 

Ears 47 



II. DISEASES OF THE CIRCULATORY SYSTEM. 

1. Diseases of the Heart and Blood-vessels in Their Relation to the 

Nose, Pharnyx, and Larynx 52 

2. Diseases of the Heart and Blood-vessels in Their Relation to the 

Ear 59 



III. DISEASES OF THE DIGESTIVE SYSTEM. 

1. Diseases of the Digestive System in Their Relation to the Upper Air- 

passages 68 

Diseases and Changes in Form of the Oral Cavity in Disturbances 

of Nasal Respiration 68 

Diseases of the Digestive Organs in Relation to the Nose, 

Throat, and Larynx 70 

2. Digestive System and Diseases of the Ear 76 



CONTENTS. 



IV. DISEASES OF THE BLOOD. 

PAGE 

1. Anemia 8i 

2. Leukemia 83 

Alterations in the Upper Air-passages in Leukemia 83 

The Manifestations of Leukemia in the Ear 86 

3. Hemorrhagic Diatheses 89 



V. CHRONIC CONSTITUTIONAL DISEASES. 

1. Rachitis 92 

2. Acromegaly 95 

3. Diabetes Mellitus 96 

4. Gout 102 

Ictus Laryngis Occurring in the Course of Obesity, Gout, and 

Diabetes 104 



VI. ACUTE INFECTIOUS DISEASES. 

1. Measles 108 

2. Scarlatina 112 

3. Varicella I20 

4. Variola 121 

5. Typhoid Fever 123 

6. Iniiuenza . I32 

Aural Complications in Influenza 134 

7. Parotitis Epidemica (Mumps) 138 

8. Acute Rheumatoid Arthritis 139 

9. Diphtheria 142 

10. Erysipelas I47 

11. Malaria 148 



VII. CHRONIC INFECTIOUS DISEASES. 

1. Tuberculosis and Lupus 15 1 

Tuberculosis of the Nose 158 

Tuberculosis of the Pharynx 161 

Tuberculosis of the Larynx 162 

Tuberculosis of the Ear 169 

Lupus 174 

2. Leprosy 177 

3. Malleus Humidus (Glanders) 183 

4. Foot-and-mouth Disease 184 

5. Anthrax 185 

6. Actinomycosis 185 

7. Rabies 186 

8. Trichinosis 187 



VIII. DISEASES OF THE KIDNEY. 

Edema of the Pharynx and Larynx ...... 188 

Hemorrhages in the Pharynx and Larynx 189 

Nephritic Aural Diseases 189 



CONTENTS. 1 3 



IX. DISEASES OF THE SKIN AND OF THE SEXUAL 
ORGANS. 

PAGE 

1. Diseases of the Skin 193 

2. The Influence of Normal or Pathologically Altered Sexual P'unctions 

on the Upper Air-passages 197 

Relation of the Sexual Organs to the Upper Air-passages . . . 197 

Relations between the Sexual Organs and the Ears 201 

3. Gonorrhea 203 

4. Syphilis 205 



X. DISEASES OF THE EYE. 

1. Relations between the Eye and the Nose 224 

2. Relations between the Eyes and the Ears 234 



XI. INTOXICATIONS. 

Acids and Alkalies 242 

lodids . 243 

Arsenic and Lead 245 

Mercury . 246 

Copper, Phosphorus, etc 247 

Quinin, Salicylic Acid, etc 248 

Chloroform, Tobacco, Alcohol 249 



XII. NERVOUS DISEASES. 

1. General Remarks on Diseases of the Larynx in Diseases of the 

Central Nervous System 251 

Diseases of the Sensory and Motor Nerves of the Larynx ... 251 
Localization of Centers for Movement of the Vocal Cords in the 
Central Nervous System, and the Effect of Diseases of the 

Central Nervous System 258 

2. General Remarks on the Aural Disturbances Produced in Diseases of 

the Central Nervous System 263 

The Mechanism of Functional Disturbances in the Ear and the 

Electric Reactions of the Auditory Nerve 263 

The Localization of the Ear in the Central Nervous Organs . . 270 

3. Nervous Diseases which Produce Definite Alterations in the Nose, 

Pharynx, and Larynx, and in the Ears 275 

Diseases of the Spinal Cord 275 

Tabes Dorsalis 275 

Multiple Sclerosis 289 

Diseases of the Medulla Oblongata 291 

Syringomyelia 29I 

Progressive Amyotrophic Buliiar Paralysis 292 

Neuroses ; 293 

Paralysis Agitans 293 

Epilepsy 294 

Chorea Minor 295 

Hysteria 295 



14 CONTENTS, 



APPENDIX. 

PAGE 

Nasal Reflex Neuroses 306 

The Significance of Some of the Cranial Nerves in Rhinology and Otology, 314 

The Trifacial Nerve 314 

The Chorda Tympani 320 

The Facial Nerve 323 

Diseases of the Meninges and of the Cerebral Sinuses 325 

Their Significance in Connection with the Nose, Larynx, and Ears . . 325 

Diseases of the Meninges in Nasal Affections 328 

Diseases of the Meninges and of the Cerebral Sinuses in Ear 

Disease 330 

INDEX 337 



RHINOLOGY 
LARYNGOLOGY AND OTOLOGY 



AND THEIR 



SIGNIFICANCE IN GENERAL MEDICINE 



[. DISEASES OF THE RESPIRATORY ORGANS. 



J. GENERAL REMARKS ON THE RELATIONS 

EXISTING BETWEEN THE NOSE, 

PHARYNX, AND LARYNX. 

The upper air-passages, comprising the nose, pharynx, 
and larynx, present a canal of varying form and diameter, 
lined in its entire extent, except where the respiratory and 
alimentary tracts cross each other in the pharynx, by mucous 
membrane covered with ciliated columnar epithelium ; so 
that nose, pharynx, and larynx imperceptibly merge one 
into the other without the interposition of a sharp line of 
demarcation. It follows that pathologic changes in any 
portion of the upper air-passages are not sharply limited in 
their local effects and ultimate consequences, but invade 
adjacent areas quite irrespective of the anatomic boundaries 
of nose, pharynx, and larynx. 

It is well known that catarrhal affections of the upper 
air-passages are not limited to a circumscribed area ; they 
display, on the contrary, a peculiar descending character, 
as it is called, beginning in the nose as an acute rhinitis and 
invading at certain definite intervals the pharynx and the 
larynx. 

The comparative immunity enjoyed by the larynx as 
compared to the pharynx is not altogether accidental, 
although to a certain extent dependent on accidental 
causes, for it is generally admitted that progressive morbid 
processes meet with a certain resistance wherever the char- 
acter of the epithelium changes, which resistance may be 
sufficient to arrest their further advance. Now, the ciliated 
columnar epithelium of the nose and nasopharynx is re- 
placed in the oral pharynx by squamous epithelium, which 
extends as far as the upper border of the larynx ; but at 
this point the epithelium returns to the ciliated columnar 
type of the higher air-passages, and this type is retained 
2 17 



1 8 THE RESPIRATORY ORGANS. 

throughout the interior of the larynx — with the exception 
of a zone of squamous epithehum extending over the 
interarytenoid notch to the posterior wall and to the vocal 
cords. Hence we can readily understand that the boun- 
daries between these various kinds of epithelium oppose to 
the progress of an acute catarrh a barrier more or less 
insurmountable, according to the intensity of the process 
and the disposition of the individual. In the comparatively 
rare cases where the larynx becomes involved in a de- 
scending catarrh, the laryngeal symptoms develop several 
days after the first appearance of the nasal and pharyngeal 
symptoms, or even after convalescence has begun in the 
higher air-passages. 

Ascending catarrh, on the contrary, differs diametrically 
from the descending form in the matter of frequency, and it 
seldom or never happens that an acute pharyngitis or laryn- 
gitis spreads to the higher portions of the respiratory tract. 

With the infectious diseases, especially diphtheria, the 
case is quite different ; they may originate either in the 
pharynx or in the nose, although, as a matter of fact, they 
usually appear first in the pharynx, and spread from that 
region either upward into the nose or downward to the 
larynx. 

The relation between the nose and the nasopharynx 

is a particularly intimate one, so much so that only very 
few diseases are limited to one or the other of these two 
structures. Any chronic condition leading to obstruction 
and to the passage of morbid products — such as mucus 
and pus — into the nasopharynx exerts an injurious effect 
on that structure ; and, conversely, any disease of the 
nasopharynx, by causing chronic enlargement of the phar- 
yngeal tonsils, thereby obstructing the nasal passages and 
interfering w'ith nasal respiration, sets up a congestive 
catarrh ; the secretions accumulate as the expiratory blast 
is no longer able to remove them, and a hyperplasia of the 
mucous membrane eventually results. 

If, on account of obstruction, the nasal secretion is unable 
to make its escape outward and flows back into the nasor 
pharynx, the harm which results is not confined to this 
locality ; the discharges trickling down along the posterior 
pharyngeal wall accumulate in the oral pharynx, and the 
subsequent course of the disease then depends on the 



SIGNIFICANCE OF THE UPPER AIR- PASSAGES. 1 9 

quantity and consistency of the morbid secretion. If the 
patient is unable to remove it by hawking and coughing, it 
will adhere to the posterior pharyngeal wall in the form of 
a thick, tenacious coating, and thence will gradually spread 
to the posterior wall of the larynx. This mode of spread- 
ing from the nose to the pharynx and larynx is especially 
characteristic of certain definite diseases, the most typical 
of which is atrophic rhinitis with fetor and crust formation. 
The greenish-yellow, foul-smelling crusts with which the 
atrophied nasal cavities are covered — as the walls of a room 
are covered with wall-paper — are also found clinging to 
the roof and posterior wall of the pharynx, while in the 
larynx a tenacious material accumulates on those parts 
which are least concerned in the movements of phonation 
and respiration, especially in the region below the glottis. 
Similar consequences attend any chronic inflammation of 
the nose, accompanied with copious secretion and suppura- 
tive processes in the tributary cavities of the nose, whenever 
the position of their openings permits a backward flow of 
pus. 



2. RELATIONS EXISTING BETWEEN THE NOSE, 
PHARYNX, LARYNX, AND LUNGS, 

SIGNinCANCE OF THE UPPER AIR-PASSAGES IN THE 
PHYSIOLOGY OF BREATHING. 

Leaving the description of the interdependence of nose, 
pharynx, and larynx, which really belongs to the domain of 
special pathology, we now turn our attention to the influence 
exerted on the lungs by disease of the upper air-passages. 

The first requisite for a thorough understanding of this 
subject is a knowledge of the physiologic significance of the 
air-passages in the act of respiration. They should not be 
viewed merely in the light of canals for the transmission of 
the inspired air ; for each segment has a special function of 
its own and contributes to the preparation of the air for 
reception in the lungs, and this function can not remain in 
abeyance without detriment to the organism. 

We begin with the consideration of the upper air-passages 
as the respiratory pathway and with the changes experienced 
by the inspiratory air-current during its passage through 
the nose. 



20 THE RESPIRATORY ORGANS, 

I. The Nose as the Respiratory Pathway. — The nose 
is the portal through which the air gains admittance to the 
body, and it has certain special functions to perform which 
lend to it a greater importance than belongs to the pharynx 
and larynx. It is charged with the duty of preparing the 
air for its entrance into the deeper air-passages, in the fol- 
lowing ways : 

1. By removing foreign substances as much as possible. 

2. By warming the air. 

3. By imparting to the air the requisite degree of 
moisture. 

4. A subordinate function consists in protection of the 
organism by means of the sense of smell and the nasal 
reflexes. 

In order to gain a full understanding of these various 
functions let us examine the path followed by the air in its 
transit through the nose. Even at the present day we 
frequently hear of the division of the nasal cavity into a 
respiratory and an olfactory region, the former correspond- 
ing with the maxillary, and the latter with the ethmoidal, 
portion. It should follow from this subdivision that the 
lower half of the nose, as far as the middle turbinated bone, 
is concerned exclusively in the act of breathing, while the 
remaining upper half subserves solely the sense of smell. 
Experimental researches prove, however, that such a 
division is not justified, either by the nature of the respira- 
tory air-current or by the distribution of the nerves, to 
which we shall return later. Experiments have been made 
by Paulson, Kayser,^ Franke,^ and Scheff,^ and those of 
Scheff have recently been repeated and confirmed by 
Danziger.* The perfect agreement of these experiments 
and the convincing care with which they were performed, 
justify us in rejecting the older theory, according to which 
the respiratory air-current passes only through the lowest 
segment of the meatus nasi communis : that is, the space 
between the inferior turbinated bone and the septum. The 
most important fact brought out by recent investigations is 
that the respiratory current passes principally through the 
middle and upper parts of the nose, and hardly touches the 

1 "Zeitschr. f. Ohr.," vol. XX, p. 96. 

2 " Arch. f. Laryng.," vol. I, p. 230. 

3 *' Klin. Zeit- u. Streitfr.," Vienna, 1895, vol. IX, part U. 

4 "Mon. f. Ohr.," 1896, p. 331. 



THE NOSE AS THE RESPIRATORY PATHWAY. 21 

inferior meatus under normal conditions. As the entrance 
to the nose is in the horizontal plane, the current of air, on 
entering, rises in a line parallel to the dorsum of the nose ; 
it is then deflected backward in the region of the agger 
nasi (which in man is rudimentary), describing a curve, the 
concavity of which faces downward, while its apogee may 
project above the superior, and never falls below the middle 
turbinated bone, and passes out through the upper half of 
the posterior nares. According to Franke, the air-current 
also forms an eddy somewhere in the region of the inferior 
turbinated bone. During expiration the curve is flattened, 
its elevation being in direct proportion to the depth of the 
inspiratory movement. 

While we must accept this as the type of nasal respira- 
tion to be considered in judging of pathologic conditions, 
we must also take into account the shape of the external 
nose, the position of the anterior nares, and the width 
from side to side of the internal openings — which depends 
on the prominence of the plica alaris. The significance of 
these factors was shown by Kayser in his experiments to 
determine the manner of aspiration in variously shaped 
noses. In the narrow, aquiline variety of nose, in which 
the external opening is horizontal and the inner opening 
usually small, the air-current follows the direction which 
has been described ; on the other hand, we have the testi- 
mony of various authors that in the broad, turned-up, so- 
called pug-nose, in which the space between the septum 
and the plica vestibuli is large, the air-current enters in a 
more horizontal direction, and is directed toward the lower 
portion of the nose. 

This apparently complicated arrangement enables the 
nose to fulfil the three different functions which pertain to 
it in the preparation of the respiratory air-current, by in- 
suring the greatest possible extent of contact with the walls 
of the nasal cavities. 

I. Removal of Foreign Substances from the Respira= 
tory Air=current. — When we consider the great variety 
of conditions with which we are surrounded, it is self- 
evident that the purity of the air, which depends on the 
presence or absence of dust and gaseous substance, is sub- 
ject to considerable change. Under the head of dust we 
have to consider solid particles of a mineral or vegetable 
nature and microorcranisms. 



22 THE RESPIRATORY ORGANS. 

The nose is provided with various means of defense 
against the entrance of these deleterious substances : the 
vibrissas which hne the inner margin of the nostrils, the 
moist surface of the mucous membrane, the reflex act of 
sneezing, and, lastly, a bactericidal property which probably 
resides in the mucous secretion. 

The vibrissae act like a coarse filter which arrests the 
larger particles. The moist surface of the mucous mem- 
brane attracts and holds fast any foreign substances in the 
air-current as it passes through the narrow and complicated 
passages of the nose. This occurs especially at certain 
points where the current impinges on the surface of the 
mucous membrane and is deflected, necessitating a certain 
amount of friction between the air and the walls of the 
cavities. In consequence of this friction, the dust particles 
suspended in the air-current are brought into close contact 
with the mucous membrane, and stick fast to its moist 
surface, later to be swept out by the outward current 
of the ciliated epithelium. One important region of this 
kind is found on the cartilage of the septum, at the level of 
the inferior turbinated bone, at the spot where the inspired 
current, after being deflected inward by the plica vestibularis, 
strikes the septum ; another corresponds to the posterior 
pharyngeal wall, opposite the posterior nares. The purifi- 
cation which the air undergoes in the nose does not, how- 
ever, entirely prevent the inhalation of dust into the lungs, 
as we know from the occurrence of anthracosis and other 
forms of pneumoconiosis. A similar resistance is offered 
by the tissues of the nose to the entrance of microorgan- 
isms. Considering the number of bacteria contained in the 
air, and the great quantity of air that passes through the 
nose, we would expect to find a very large number of 
microorganisms in the nasal chambers, as it is probable 
that they do not penetrate into the deeper air-passages. 
Opinions are divided on the fate of germs introduced into 
the nose, both as to the depth to which they penetrate into 
the nose and as to their behavior therein. While some in- 
vestigators state that the nose is a playground for all kinds 
of bacteria, others, like Thomson and Hewlett, ^ have 
recently advanced the theory that the germs are arrested 
in the vestibule, and only in exceptional cases and in 

1 " Medico-Chirurgical Transactions," vol. LXXVni, 1895. 



THE NOSE AS THE RESPIRATORY PATHWAY. 23 

small numbers penetrate into the deeper portions of the 
nose. 

The question whether the nose contains germs under 
normal conditions has a practical bearing. There have 
been found the staphylococcus pyogenes aureus, the pneu- 
mococcus of Friedlander, the streptococcus, the diplococ- 
cus of Frankel-Weichselbaum, diphtheria bacilli, and count- 
less other bacteria of less importance, and Straus has 
shown that tubercle bacilli are frequently present in the 
noses of healthy individuals living among phthisical patients. 
But it is a matter of everyday observation that injuries or 
operative wounds in the nose usually heal without causing 
any, or at any rate very little, general disturbance, in spite 
of the apparent danger from infection which should result 
from the presence of such large numbers of bacteria. The 
explanation of this want of virulence on the part of the 
germs in the nasal cavities has been sought in a bactericidal 
quality of the mucous secretions. This was assumed by 
Wurtz and Lermoyez.^ but Thomson and Hewlett found 
that the nasal mucus is not directly bactericidal, although 
it arrests the growth of germs to a certain extent. It is 
idle, in the absence of exact proofs, to discuss this question 
of the bactericidal powers of the secretion. The most that 
can be said is that it is not a favorable soil, and hinders the 
development of the microorganisms more or less. The 
conditions in this respect are evidently analogous to those 
found in the oral cavity, which contains even a greater 
abundance of bacteria. The mere presence of germs is not 
in itself injurious to the nose ; other factors must be taken 
into account : the number and virulence of the pathogenic 
germs which gain entrance ; the disposition of the individ- 
ual ; and the presence of other bacteria, which either assist 
or retard the growth of the pathogenic varieties. 

2 and 3. Warming and Saturation of the Inspired Air. 
— It has been proved by the experiments of Aschenbrandt 
and of R. Kayser,^ that the temperature of the air-current 
during its passage through the narrow chambers of the 
nose is raised to from 25° to 35° C, depending on the 
external temperature. It would, however, be wrong to 
suppose that this function of the nose is indispensable 
for breathing ; Kayser has shown that the inspired air is 

1 " Ann. des mal. de I'oreille," 1893, p. 661. 

2 " Pfliiger's Arcliiv," vol. XI.I. 



24 THE RESPIRATORY ORGANS. 

warmed only half a degree less in mouth-breathing than 
in nasal respiration, and that after tracheotomy the trachea 
and bronchi are quite capable of warming the air to 30° 
C. — the average temperature imparted to it in the nose 
— without injury to the lungs. Gaule suggests that the 
abundant supply of blood-vessels in the nose, and the 
property possessed by them of changing their volume, 
enable them to adapt themselves more easily to the ther- 
mic changes of the outside air. 

A far more important function of the nose is to supply 
the necessary moisture to the inspired air — a function which 
the mouth is unable to perform. The nose thus relieves 
the bronchi and lungs of an onerous duty, which falls on 
them to a much greater degree if respiration is performed 
through the mouth. 

To enable it to supply the required amount of moisture 
the nose is endowed with unusual secretory activity. The 
latter is derived in part from the abundant supply of serous 
and mucous glands and from an extensive system of lym- 
phatics ; also in part from an " irrigation-system, which 
keeps the epithelium constantly supplied with the necessary 
amount of moisture." The source of this special system 
is to be sought, according to Schieffendecker, not in the 
lymphatic vessels, but in the lymph-spaces of the tissues, 
the moisture making its way to the surface through the 
basal canaliculi, which pierce the basal membrane and 
emerge between the epithelial cells. 

4. In addition to these functions of the nose, there are 
other protective contrivances of less importance in the 
upper air=passages, which prevent the entrance of deleteri- 
ous substances into the lungs. Thus, the sense of smell 
serves to protect the organism by testing the inspired air 
and guarding the lungs against the entrance of substances 
which can be recognized by their odor. This protection 
is, after all, a faulty one, as there are many odorless gases 
which are injurious to the lungs and can not be detected in 
the inspired air by the sense of smell. 

In the physiologic reflexes the body possesses another 
means of ridding itself of coarse particles of matter that 
have gained entrance to the nose with the inspiratory air- 
current, the mucous membrane bringing the sneezing reflex 
into action. 



PHARYNX AND LARYNX AS RESPIRATORY PATHWAYS. 25 

It is thus seen that under normal conditions respiration 
is effected through the nose, the hps being closed and the 
oral cavity occluded anteriorly and posteriorly by means 
of the tongue. The latter completely fills the oral cavity 
during nasal respiration, its tip being pressed against the 
upper teeth and the dorsum and edges fitting against the 
palate and alveolar processes, while the base of the tongue 
arches upward and is closely applied to the soft palate, so 
that the oral cavity is hermetically closed and shut off 
from the pharynx. 

The question presents itself, whether the mouth is capa- 
ble of supplying the functions of the nose in preparing the 
air for respiration, or whether mouth-breathing is injurious 
to the organism ; and the answer must be that the oral 
cavity is not in any way adapted to replace the nose in the 
act of breathing. The width of the oral cavity is such 
that the air-current encounters no resistance, and conse- 
quently its progress is not retarded, as it is in the narrow 
passages of the nasal cavity, and no time is afforded for 
purification and saturation. The less abundant vascular 
supply and the absence of cavernous tissue (the amount of 
blood in which is regulated by the external temperature, 
and thus tends to maintain the required degree of tempera- 
ture in the nose) ; the absence of an abundant watery secre- 
tion in the oral cavity ; the nature of the epithelium in the 
mouth, which is of the squamous variety, and therefore in- 
capable, in contradistinction to the ciliated epithelium in 
the nose, of removing automatically any deleterious sub- 
stances in the air-current all these structural differences 
combine to make the mouth unfit to supply an air-current 
which would be other than injurious to the organism. 

II. Pharynx and Larynx as Respiratory Pathways. 
— When the air reaches the pharynx and larynx, after 
passing through the nose, it has undergone the necessary 
preparatory changes for its entrance into the lungs, and 
needs no further alteration of any moment. If any par- 
ticles of dust enter the larynx with the inspired air, they are 
promptly expelled by the ciliated columnar epithelium. 
But the pharynx and larynx are nevertheless supplied with 
a protective apparatus capable of preventing the passage of 
foreign bodies in either direction — into the postnasal space 
and the nose, or into the trachea and deeper air-passages ; 
and it is called into activitv whenever food is taken, to 



26 THE RESPIRATORY ORGANS. 

guard the air-passages against the invasion of food par- 
ticles. The oral cavity is completely shut off from the 
rhinopharynx by the application of the soft palate against 
the posterior pharyngeal wall, but the larynx is not entirely 
occluded during deglutition, the bolus of food gliding easily 
into the esophagus over the arching dorsum of the tongue 
(which guards the entrance to the larynx), so that the 
action of the epiglottis in closing the larynx is not abso- 
lutely indispensable. If a foreign body, however, does get 
into the larynx, the glottis immediately closes,- — as it does 
always at the slightest touch, — and the offending particle is 
expelled by coughing. 



DISEASES OF THE LUNGS DUE TO DISTURBANCES OF THE 
PHYSIOLOGIC FUNCTION OF THE UPPER AIR-PASSAGES. 

In returning from this physiologic digression to the dis- 
cussion of the influence exerted on the respiratory organs 
by disease of the upper air-passages, I shall adopt a classi- 
fication in which the first place is accorded to those diseases 
of the lung that develop in consequence of disturbances 
of the function of the upper air-passages. 

Such disturbances may arise because the respiratory air- 
current can not make its way through the nose, so that 
mouth-breathing becomes necessary. The obstruction may 
be situated in the nose or in the postnasal space. Any one 
of the following conditions may be present, and necessitate 
mouth-breathing : Hyperplasias and tumors in the nose ; 
structural anomalies in the framework of the nose obstruct- 
ing the lumen, caused by deviation of the septum, by 
ridges on its surface, or by abnormal bulging or cystic 
formations in the muscles ; occlusion of the posterior 
nares by tumors in the postnasal space, and especially by 
adenoid growths on the vault of the pharynx. The evil 
effects of mouth-breathing first manifest themselves in the 
mucous lining of the pharynx and larynx, which becomes 
dry because the air has not been properly prepared and 
saturated. Dust particles are deposited first on the mucous 
membrane of the mouth and oral pharynx — which is cov- 
ered only with squamous epithelium — and later make their 
way into the larynx and deeper air-passages. The con- 
stant irritation of the dry and unpurified air coming in 
contact with the mucous membranes of the upper and lower 



DISEASES OF THE LUNGS. 2/ 

air-passages gives rise, as we can easily understand, to 
chronic catarrhal conditions. Thus it is found that mouth- 
breathers, as represented typically by children in the early 
stages of enlarged tonsils, are prone to become the subjects 
of catarrh of the upper air-passages, of recurring pharyn- 
geal and laryngeal catarrh, and of acute bronchial catarrh ; 
while if the condition continues, they usually develop 
chronic bronchitis, which can be permanently cured only 
by restoring nasal respiration. 

In this way we can frequently explain the chronic catarrh 
which is seen almost constantly in children of scrofulous 
habit, in whom the hypertrophy of the lymphatic elements in 
the postnasal space is followed by occlusion of the posterior 
nares. Mouth-breathing is, however, not the only pre- 
cursor of chronic catarrh in the deep air-passages ; the 
condition frequently develops as a sequel to pathologic 
alterations in the nose itself, provided they are sufficient to 
render it unfit to afford the necessary protection to the lungs. 
In atrophic conditions of the nose, coupled, as they are, 
with metaplasia of the epithelium, foreign bodies contained 
in the inspired air cling to the walls of the cavities, and 
eventually penetrate into the deep air-passages. In examin- 
ing persons afflicted in this way, whose work obliges them 
to breathe impure air, a mere inspection of the nose, pharynx, 
and larynx shows the dust-particles, whether mineral or 
vegetable, as, for instance, coal-dust and flour, clinging to 
the mucous surface, and it is easy to understand that these 
dust-particles may be carried down with the inspiratory 
blast and settle in the bronchi. Suchmorbid changes must 
necessarily favor the development of the various forms of 
pneumoconiosis, especially anthracosis and chalicosis. 

Disturbances of the sensibility and of the reflex activity 
of the pharynx and larynx have an important bearing on the 
lungs and bronchi, as they facilitate the development of 
inspiration pneumonia. If there is anesthesia of the pharynx 
and larynx, and the cough reflex is diminished, it is easy for 
particles of food to enter the larynx ; and when from 
anesthesia of the larynx the glottis fails to close, and 
there is no reflex cough, the offending body readily finds its 
way into the lower air-passages. Hence an inspiration 
pneumonia frequently complicates nervous affections, which, 
like diphtheria, are accompanied with disturbances of sensi- 
bilitv\ or, like bulbar disease, witli loss of reflexes. 



28 THE RESPIRATORY ORGANS. 

On the other hand, it is worthy of remark that ulcera- 
tions and disturbances of mobihty in the epiglottis do not, 
as a rule, interfere with deglutition, and therefore are not 
followed by inspiration pneumonia. Motor disturbances of 
the epiglottis are usually mechanical, being due to inflam- 
mation and swelling of the member, while ulcerations, 
which may be so great as to destroy the entire organ, usu- 
ally result from syphilitic or tuberculous lesions. When 
either of these conditions is present, we should naturally 
expect that food particles would penetrate into the air- 
passages, the entrance to the larynx not being sufficiently 
occluded by the epiglottis. The fact that it does not hap- 
pen is proof that the epiglottis is of no great importance as 
a protection to the larynx, its place being easily filled by 
the base of the tongue. If, however, the muscles of the 
tongue are paralyzed or atrophied, as in progressive bul- 
bar paralysis, foreign bodies find no difficulty in entering 
the deeper air-passages. 

DISEASES OF THE LUNGS IN MORBID CONDITIONS OF 
THE UPPER AIR-PASSAGES. 

Diseases of the lungs may owe their origin to direct ex- 
tension of disease of the upper air-passages to the trachea 
and bronchi. The causes are the same as those we have 
referred to in discussing the relations existing between dis- 
eases of the upper air-passages, chronic hypertrophic and 
chronic atrophic catarrh, and suppurative processes in the 
nose, in its tributary cavities, and in the postnasal space. 
Chronic bronchitis is the most frequent of the various 
sequels, and proves very obstinate, especially in cases of 
chronic suppuration in the tributary cavities of the nose, 
where the pus trickles down from the nasal pharynx into 
the deep air-passages and sets up a chronic irritation. The 
question of the relation between chronic catarrh of the 
upper and of the deeper air-passages has not received the 
attention it deserves ; it is barely mentioned in the most 
general terms in connection with bronchitis, and the pos- 
sibility of emphysema, bronchiectasis or fetid bronchitis 
being due to such causes is usually ignored. A paper by 
Sticker, 1 in which he establishes a causal relation between 
atrophy, or dry catarrh of the mucous membranes of nose 

1 "Arch. f. klin. Med.," vol. LVII. 



DISEASES OF THE LUNGS. 2g 

and pharynx, and similar atrophic conditions in the trachea, 
bronchi, lungs, and pleura, is therefore worthy of notice. 
Genuine ozena, or rhinitis foetida atrophica, is an atrophic 
process in the mucous membrane, shared to some extent 
by the skeleton of the nose, so that the turbinated bones 
are often entirely destroyed, and the nasal cavity attains 
enormous dimensions. The atrophy affects the glands and 
the erectile tissue, partly destroying both structures, but 
does not extend to the blood-vessels, which, on the con- 
trary, according to recent investigators, become dilated. 
At the same time the ciliated cylindric epithelium is con- 
verted into horny squamous epithelium, giving the mucous 
membrane a dry, cicatricial appearance, which in the later 
stages also extends to the pharynx and larynx after the 
atrophic process has reached these parts. The disease 
is regularly accompanied by the secretion of a tenacious 
material, which dries, forms crusts, and gives off a 
characteristic penetrating fetor. The discharges make 
their way into the pharynx and larynx, and thence into 
the deeper air-passages, where they may set up chronic 
irritative conditions. Sticker has shown that, aside 
from the fact that diseases of the lungs may be caused 
by disease of the deeper air-passages secondary to a similar 
process in the nose and postnasal space, there is a general 
condition of which the atrophy of the mucous membrane is 
merely the superficial expression, and this he has called 
xerosis of the mucous membranes. This condition event- 
ually leads to a wide-spread and more or less complete 
atrophy of all the mucous membranes in the body, and, as 
old age comes on, to a progressive increase in the size of 
the nasal and postnasal cavities, the larynx, the trachea, 
the bronchi, and, finally, the lungs. In cases of marked 
atrophy with ozena of the nose and pharynx experience 
teaches us to expect not only chronic bronchitis, but also 
emphysema and asthma-like attacks. If such a condition 
is met with in elderly persons who have all their lives suf- 
fered from chronic bronchitis due to ozena, it is readily ex- 
plained as senile emphysema, or as a secondary emphy- 
sema, such as may develop gradually in chronic bronchitis. 
But how are we to explain such cases of pulmonary em- 
physema in young persons, barely twenty years old, with 
all the symptoms — especially dyspnea and cyanosis — which 
are found only in the severest grades of emphysema? I 



30 THE RESPIRATORY ORGANS. 

remember particularly a healthy young farmer, twenty-one 
years old, who suffered from severe emphysema, and the 
only explanation that could be found was a marked ozena, 
which the patient said he had had for a long time. Great 
as was the temptation to establish a causal relation between 
the two diseases, there did not seem to be sufficient justifi- 
cation for doing so, if the lung disease was viewed merely 
as secondary to the disease in the postnasal space. Such 
cases confirm Sticker's theory of a general xerosis. The 
tendency of the finer bronchioles to a dry catarrh, leading 
to simple increased volume (volumen pulmonum acutum) 
and pulmonary emphysema, is interpreted by Sticker in his 
previously mentioned paper, as an expression of the gen- 
eral xerosis which primarily affects both the upper and 
lower air-passages. 

But how does this xerosis originate? Is it a disease, 
brought on by external influences, by bacteria, by suppura- 
tions or excoriations in the nose, which is hidden under the 
disguise of what we call genuine ozena? Every one of 
the hypotheses that have been advanced to explain the 
occurrence of atrophic fetid rhinitis must be rejected as in- 
adequate. All the various causes, from alterations in the 
epithelium, glands, and blood-vessels to the latest bacterio- 
logic discoveries, to which the symptom-complex known as 
ozena has been attributed, while they may possess some 
accessory importance, are certainly not the primary etio- 
logic factors. The production of a fetid secretion with a 
tendency to crust formation is not peculiar to ozena. Ex- 
perience teaches that it may occur in any condition in which 
the capacity of the nose is increased, whether from destruc- 
tion of the skeleton or from too severe treatment with the 
galvanocautery, or any form of atrophy of the mucous mem- 
brane. There is nothing new about Sticker's suggestion of 
syphilis as the cause of his mucous membrane xerosis. 
Stork repeatedly emphasized the probability of a causal 
relation between ozena and hereditary syphilis ; but Sticker 
put the matter in a clearer light when he showed that the 
conspicuous local alterations in the nose are comparatively 
unimportant, and that the general xerosis is the primary 
condition, corresponding to a postsyphilitic destruction of 
the parenchyma, which may, by becoming complicated with 
chronic catarrh, give rise to ozena with its characteristic 
secretion. 



ALTERATIONS IN THE UPPER AIR-PASSAGES. 3 I 

It is at least worth while to examine this xerosis of the 
upper and lower air-passages, in order to determine whether 
chronic bronchitis and emphysema are really due to the 
same cause as the disease of the nose and postnasal space. 

Among- pathologic curiosities may be mentioned the 
cases in which corrosive fluids penetrate into the larynx, 
trachea, and bronchi. There have also been reported 
instances of fibrinous exudations due to vapor of ammonia 
being formed in the nose, pharynx, larynx, trachea, and 
even in the finest bronchioles (Hoffmann). Phthisical patients 
who had been treated for a long time with local applica- 
tions of lactic acid on account of tuberculosis of the 
larynx have been known to expectorate ribbon-like shreds 
of mucus from the trachea and bronchi. ^ 

Scleroma of the upper air-passages which, as Schrotter ^ 
and Baurowicz ^ had occasion to observe, extends to the 
bronchi and leads to stenosis, is a very rare condition, at 
least in this country. Schrotter's patient died of maras- 
mus and fetid bronchitis ; Baurowicz' s, of asphyxia brought 
on by stenosis of the bronchi. 

ALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES 
OF THE LUNGS. 

The most important alterations in the upper air-passages 
occurring in the course of the various diseases of the lungs 
are those which are due to the irritation of the mucous 
membranes by the passage of the secretions. Any chronic 
disease of the lungs in which sputum is secreted is followed 
sooner or later by chronic laryngeal and pharyngeal 
catarrh, the intensity of which is in direct proportion to 
the amount and consistency of the expectorated material 
and to the amount of effort required to effect its expulsion. 
Hence, asthmatic and emphysematous patients, whose 
bronchi are filled with tenacious sputum which requires 
severe coughing and straining to remove, suffer more from 
inflammatory conditions of the upper air-passages than do 
those who have a simple bronchitis with watery secretions, 
which they can expel without straining the muscles of the 
neck and throat. 

^ F. A. Hoffmann, " Die Krankh. der Bronchien," in Nothnagel's 
"Spec. Path. u. Therap.," p. 135. 

* " Mon. f. Olir. ," 1895, p. 149 et seq. 
^ "Arch. f. Laryng. ," iv, p. 99. 



32 THE RESPIRATORY ORGANS. 

A form of ascending catarrh of the air-passages has 
been described, beginning with bronchitis and terminating 
in acute larjmgitis and pharyngitis. Emphysematous in- 
dividuals suffer from congestive catarrh, and are prone to 
have hemorrhages. 

According to Heinze ^ and Landgraf,^ croupous pneu- 
monia is sometimes followed by laryngeal complications. 
Among fifty cases of laryngeal ulceration, Heinze found one 
in which the vocal cords were ulcerated in the course of 
croupous pneumonia, and he states that the ulcerations were 
not tuberculous. Landgraf analyzed eighty cases of croupous 
pneumonia, and found two cases of ulceration in the larynx. 
In both cases the primary disease was severe, — one being a 
bilious form and the other being accompanied by severe 
sensory phenomena, — and he attributes the ulcers to the 
dyspnea, " interpreting them as decubital ulcers analogous 
to t}'phoid ulcers" : "The closure of the glottis which 
precedes the cough — in other words, the pressure on the 
vocal processes and free borders of the vocal cords — led to 
the formation of ulcers in these situations." 

The most frequent complications of lung diseases in the 
larynx consist in paralysis, the occurrence of which after 
disease of the lungs and pleura is explained by the course 
of the recurrent larjmgeal nerve. The plications ^ which 
form in the pleura over the apices in chronic inflammations 
are very apt to include the nerve, especially on the right 
side, where such a complication is favored by the relation of 
the nerve to the subclavian artery ; and, on the other hand, 
indurations of the apex may during cicatrization exert 
traction on the nerve. Paralyses of the right or left 
recurrent are most frequent in chronic indurative pleuritis, 
and produce permanent alterations in an acute left pleuritis. 
Schrotter * once observed a paralysis, which disappeared 
after ten days, and infers that it was a case of inflamma- 
tory edematous infiltration of the pleura. Paralysis rarely 
develops in pleural exudations. Moeser ° claims to have 
observed that patients with pleural exudations, particu- 
larly when there is a copious effusion of fluid, and oftener 

^ " Die Kehlkopfschwindsucht," p. 87. 

2 " Charile Ann.." xil, p. 244 et seq. 

3 Comp. Gerhardt, " Virch. Arch.," xxvn, p. 76. 
* " Die Krankheiten des Kehlkopfes," p. 414. 

5 " Arch. f. klin. Med.," XXXVII, p. 570 et seq. 



ALTERATIONS IN THE UPPER AIR-PASSAGES. 33 

on the right than on the left side, present peculiar motor 
disturbances of the vocal cord on the corresponding side, 
which almost always consisted in " diminished power of 
abduction "; but his observations are not sufficiently con- 
vincing, and do not present the typical picture of a pro- 
nounced paralysis of the recurrent. Nor is there more 
plausibility in the attempts to explain a paralysis occurring 
in a left pleural effusion by the downward displacement of 
the heart exerting direct traction on the aorta and the 
recurrent nerve ; or one occurring in a right effusion by the 
displacement of the heart to the left and the consequent 
traction on the vessels of the right side, especially the 
subclavian artery and the recurrent nerve which winds 
around it. 

Chronic conditions in the apex of the right lung — such 
as tuberculous consolidation or chronic induration from the 
inhalation of dust — may produce recurrent paralysis. 
Compared to the great frequency of pulmonary tubercu- 
losis, paralysis due to this condition is exceedingly rare, — 
Jurasy ^ saw only three cases, which he did not describe in 
detail, — and the diagnosis can not even be established with 
absolute certainty during life, for, as will be described later, 
the nerve may be pressed upon by swollen lymph-glands 
within the thorax. The same is true of recurrent par- 
alysis in anthracosis, examples of which are found in cases 
of Baumler ^ and Kohn,^ in which the cause of the par- 
alysis turned out to be an adhesion of the recurrent nerve 
to an indurated, deeply pigmented and contracted bron- 
chial gland. 



ALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES 
OF THE MEDIASTINUM. 

Before closing the section on the respiratory organs, 
mention should be made of alterations due to disease in the 
mediastinum and changes in the thyroid gland. 

The inferior laryngeal nerves traverse the mediastinum, 
and are, therefore, exposed to injuiy from disease in that 
locality. 

In the case of mediastinal tumors the left nerve, on ac- 

1 " Krankh. der ob. Luftwege," p. 476. 

2 Comp. Baumler, "Arch. f. klin. Med.," xxxvn, p. 231 et seq. 
' " Miinch. med. Wochen.," 1895, P- ^^Z^- 

3 



34 THE RESPIRATORY ORGANS. 

count of its position in the lowest part of the mediastinum, 
is most apt to be included within the growth. But it also 
happens, as in Michael's case/ that in spite of its more 
superficial course the right recurrent nerve becomes em- 
bedded in the tumor. 

Paralysis of the inferior laryngeal nerves may follow dis- 
ease of the bronchial lymph-glands, and of the glands be- 
longing to the group oi ganglions tracJieo-lath-aiix (Barety),^ 
designated as ganglions peiitracheo-laryngiens by Gougen- 
heim and Leval Picquechef,^ which occupy the groove be- 
tween the trachea and the esophagus, and therefore come 
into close relation with the recurrent nerve, which emerges 
from the mediastinum in the same situation on each side of 
the body. 4 

These glands often become enlarged in scrofulous chil- 
dren after bronchopneumonia and other forms of chronic 
pulmonary catarrh ; they are also found to be enlarged in 
tuberculosis and in melanotic degeneration. An example 
of the latter has recently been mentioned in Baumler's case, 
while the literature of tuberculosis of the bronchial glands 
has lately been worked up by Fronz.^ If suppuration 
take place in the glands, the abscess sometimes ruptures 
into the trachea, and the pus is evacuated into the larynx, 
as observed by Massei ^ in several cases. 

Besides pressing on the nerve-trunk, mediastinal tumors 
may push the larynx to one side or the other and compress 
the trachea. Such a stenosis from compression of the walls 
is sometimes seen in the trachea with the laryngoscope ; 
rotation of the trachea and larynx may take place, so that 
the glottis appears oblique in the laryngoscopic image. 
Struma is a more frequent cause of tracheal stenosis than 
mediastinal tumor, a large percentage of all stenoses being 
due to goiter. Rosenberg "^ found that out of fifty-four 
cases of tracheal stenosis, thirty-eight were caused by 
struma. 

The occurrence of vocal cord paralysis in struma de- 

1 "Die med. Wochen.," 1895, No. 25. 

2 Comp. F. A. Hoffmann, " Erkrankungen des Mediastinum," 1896, p. 30. 

3 " Ann. des mal. de roreille," etc., 1884. 

* An excellent illustration of these anatomic relations is found in Gougen- 
heim — Glover's " Atlas of Laryngology," I, xix. 
5 " Jahrb. f. Kinderheilk.," vol. XLIV. 
•^ ^' Rev. de lar., d'ot et de rhin.," 1897, No. 7. 
" Heymann, " Handb. der Laryng.," i, p. 568. 



THE AIR- PASSAGES AND THE EARS. 35 

pends more on the position than on the bulk of the enlarge- 
ment ; if the lateral lobes are affected, pressure is exerted 
on the nerves, and paralysis frequently results. 

Among the structures in the mediastinum which may 
affect respiration unfavorably the thymus gland must also 
be mentioned. In recent times, cases of sudden death in 
children have been attributed to hyperplasia of the thymus, ^ 
just as the inspiratory stridor of the new-born is now gen- 
erally acknowledged to be referable to the same cause. 
Siegel 2 and Avellis ^ have contributed valuable descrip- 
tions of the clinical picture presented, supplemented with 
full histories of the cases. 

A signal proof of the relation between inspiratory stridor 
and enlarged thymus is afforded by Rehn's case, reported 
by Siegel, and by a case operated on by Konig, in which 
recovery was brought about by exposing the gland, after 
resection of the sternum, and fixing it to the cervical fascia 
in one case, and by extirpating a part of the gland in the 
other. In the typical case there is labored, groaning res- 
piration, not occurring in paroxysms but persistent ; the 
dyspnea sometimes amounts to violent choking fits with 
cyanosis, so that the affection (which is also called asthma 
thymicum) has often been erroneously described as laryn- 
gismus stridulus. Since the clinical feature is not a spasm 
of the vocal cords, but a compression of the trachea and 
bronchi, the term inspiratory stridor is the most scientific, 
and should be applied at least to cases in which the diag- 
nosis of a thymic origin for the dyspnea is not quite clear. 
This compression, as M. Schmidt ^ observed in a woman, 
twenty-five years old, who had suffered from inspiratory 
stridor during infancy, may be permanent. 



3. RELATIONS BETWEEN THE UPPER AIR- 
PASSAGES AND THE EARS. 

The interdependence of the upper air-passages and the 
. ears depends, in the majority of cases, on the communica- 
tion established by the Eustachian tubes, which open into 

1 Avellis, "Arch. f. Laryng.," vni, p. 159. 

2 " Berlin klin. Wochen.," 1896, No. 40. 

3 "Miinch. med. Wochen.," 1898, Nos. 30 and 31. 
* Cited by Avellis. 



36 THE RESPIRATORY ORGANS. 

the lateral walls of the pharynx, and their function in con- 
nection with the middle ear. Hence, to understand the 
mechanism of secondary ear affections, when the primary 
disease focus is in the upper air-passages, the following 
points, which will later be described more in detail, must 
be borne in mind. 

The Eustachian tube ventilates the middle ear, and 
regulates the tension by equalizing the differences that may 
arise between the atmospheric pressure on the tympanic 
membrane in the external meatus and in the postnasal space, 
and the pressure of the air imprisoned in the middle ear. 
Whenever the equilibrium is disturbed, auditoiy disturb- 
ances result, which have their seat in the tympanic mem- 
brane and in the sound-conducting apparatus. 

Such disturbances may follow disease in the upper air- 
passages, obstructing or occluding the pharyngeal orifice, or 
interfering with the action of the palatal muscles which 
effect the opening and closing of the tube. 

The Eustachian tube represents the path by which disease 
of the pharyngeal vault spreads by continuity to the 
middle ear ; the mucous membrane of the tube becomes 
involved in any disease affecting the mucous membrane of 
the nose and pharynx ; or, in other words, the tube repre- 
sents the channel through which infection reaches the mid- 
dle ear from the upper air-passages. 



THE EFFECT OF DISTURBANCES OF THE NORMAL FUNC- 
TION OF THE EUSTACHIAN TUBE. 

For the proper comprehension of this relation a few in- 
troductory remarks are required to explain the mechanism 
by which the normal tube neutralizes the variations in pres- 
sure of the atmospheric air in the middle ear. The tube does 
not keep up a constant communication between the two air- 
chambers — that of the pharynx and that of the middle ear. 
In the state of rest its pharyngeal extremity remains closed, ^ 
and is opened only when the muscles of the palate and 
pharynx, which are devoted to its service, are brought into 
action. As the opening of the tube is effected by the tensor 
veli and levator veli muscles, the pharyngeal orifice must be 
opened whenever these muscles contract, which happens 

1 Hammerschlag, in "Wien. med. Wochen.," 1896, Nos. 39 and 40, 
makes the assertion that the tube is normally open. 



DISTURBANCES OF THE EUSTACHIAN TUBE. 37 

regularly and frequently, accompanying the act of deglu- 
tition. The opening of the tube is, therefore, under the 
control of the will power, and we can equalize any disturb- 
ances of the pressure equilibrium by the simple act of 
swallowing, which establishes a communication between the 
postnasal space and the middle ear, through the opened 
tube. We instinctively take advantage of this phenomenon 
whenever a change in the atmospheric pressure takes place, 
as in climbing high mountains, during explosions and loud 
detonations, and, artificially, for therapeutic purposes, by 
means of pneumatic chambers. 

What, then, is the result if the tube fails to maintain the 
equilibrium ? What happens when the pressure is greater 
in the pharynx than in the middle ear, either because the 
pressure of the outside air has been raised or because the 
pressure of the air in the middle ear has been lowered ? 

Valsalva's experiment, which consists in artificially rais- 
ing the air pressure in the postnasal space by making a 
forced expiration with the nose held shut, — when the pharyn- 
geal orifice of the tube is forcibly opened and the air escapes 
into the middle ear, — would appear to indicate that the 
orifice opens automatically whenever the pressure in the 
pharynx is even slightly increased. This is not the case, 
however. On the contrary, a rise in the atmospheric pres- 
sure has the efifect of closing the tube tighter than ever, for 
we know from practical as well as experimental observation 
that increased pressure in the pharynx brings the mem- 
branous wall of the tube into closer apposition with the 
cartilage, thus forming a kind of valve, which shuts the 
canal off from the middle ear. The closure effected in this 
way may be so obstinate that an ordinary act of swallowing 
is unable to overcome it. 

A rise of pressure takes place regularly in the pharynx, 
independently of changes in the atmospheric pressure, when- 
ever the tube remains closed for any length of time, and the 
air imprisoned in the cavities of the tympanum undergoes 
rarefaction. 

It follozvs, therefore, that a fall in the tympanic pressjire 
occurs in all diseases in which the pharyngeal orifice of the 
Eustacliian tube is occluded. In explanation of this phe- 
nomenon we can not do better than quote the words of 
Bezold :i " In the middle ear, as in all vascular, air-con- 
1 "Berl. klin. Wochen.," 1883, No. 36. 



38 THE RESPIRATORY ORGANS. 

taining cavities, the volume of air diminishes whenever free 
communication with the atmosphere is interrupted, because 
the oxygen enters into chemic combination with the blood 
and the amount of CO2 given up is not enough to compen- 
sate for the loss in volume." 

These pressure variations give rise to a series of clinical 
pictures which are included under the general term of 
acute or chronic middle-ear catarrh, and hav^e as their most 
prominent symptom retraction of the tympanic membrane 
— a purely mechanical result of the increased pressure in 
the external auditory meatus. In the otoscopic image 
this abnormal position and the curvature of the tympanic 
membrane find their expression in the absence of the cone 
of light from its normal situation ; in the presence of irreg- 
ular reflexes ; in displacement of the handle of the malleo- 
lus, which assumes a more horizontal position, or eventually 
even disappears behind the posterior fold ; and, finally, in 
a marked projection of the short process and handle of the 
malleolus from the retracted membrane. The subjective 
symptoms are diminished auditory acuity and tinnitus 
aurium ; occasionally the patient complains of pain. The 
question whether the occasional occurrence of exudation in 
conditions of diminished tympanic pressure is due solely to 
hypcrcEinia ex vacuo can not be answered in the affirmative 
in every case. Although the possibility of such an origin 
deserves consideration, the fact that JiypercEinia ex vacuo 
is not by any means a regular accompaniment of occlusion 
of the tube is sufficient proof that other factors must also 
be operative to produce an effusion, and it is safe to assume 
the occurrence of an irritative inflammation of the mucous 
membrane. The idea of hydrops ex vacuo is therefore limited 
in its application, and must in many cases give way to the 
theor}^ of an inflammatory exudate. This view is con- 
firmed by clinical experience, since it is found that chronic 
occlusion of the tube, which produces the greatest dimin- 
ution of density, is not, as a rule, followed by exudation. 
On the other hand, in almost all cases of occlusion oc- 
curring after acute inflammations an exudate is formed 
which betrays its inflammatory nature in the otoscopic 
image by a simultaneous swelling and congestion of the 
deeper layers of the membrana tympani, and can be ascribed 
only to inflammatory swelling of the mucous membrane of 
the middle ear, with secondarv extension to the mucosa of 



DISTURBANCES OF THE EUSTACHIAN TUBE. 39 

the membrana tympani. It follows, therefore, that the 
exudate is as much a symptom of middle-ear inflammation, 
or the time-honored "otitis media catarrhalis," as of oc- 
clusion of the Eustachian tube. The results of bacterio- 
logic investigations of this condition are not uniform enough 
to throw much light on the subject. Kanthack i found a 
great variety of pathogenic organisms in exudations follow- 
ing occlusion of the tube, while Scheibe ^ and Brieger ^ 
deny the presence of these organisms, and consider the 
" exudate ex vacuo " sterile ; hence we are not as yet jus- 
tified either in adducing the finding of microorganisms as 
proof of the inflammatory character of the exudate, or in 
denying it on the strength of a negative bacteriologic result. 
There is also a possibility of the pressure equilibrium 
being disturbed by an excess of pressure in the middle ear, 
most frequently due to a fall in the atmospheric pressure. 
Its pathologic significance is slight compared to the oppo- 
site condition. The rise in pressure is readily equalized by 
the tube, because, as previously described, there is no occlu- 
sion of the pharyngeal orifice by the air pressure, and the 
equilibrium is therefore easily restored by the act of deglu- 
tition. Hence a gradual fall in pressure, such as is ex- 
perienced in balloon ascensions and in mountain climbing, 
is easily borne, because the excess of pressure which at 
first occurs in the middle ear soon accommodates itself to 
the surrounding conditions. On the other hand, when the 
external pressure is suddenly removed, the excessive pres- 
sure in the middle ear is very apt to produce disturbances 
in the auditory organs by rupture of the membrana tym- 
pani. This is apt to occur when men are released from a 
caisson without the necessary precautions. Sudden rise of 
pressure in the middle ear is sometimes produced by blow- 
ing the nose, if the pharyngeal orifice is forcibly opened by 
a sudden increase in pressure in the postnasal space, allow- 
ing the air to escape through the tube. It is particularly in 
cases of nasal obstruction, when the expiratory blast can not 
escape and becomes imprisoned in the postnasal space, that 
violent blowing of the nose is apt to be followed by serious 
consequences in the ear, by producing hemorrhages or 
rupture of the membrane, especially if the latter is diseased 
or atrophic. 

1 " Zeitschr. f. Ohr.," XXI. 2 "Zeitschr. f. Ohr.," xxiii. 

3 " Deitr. z. Ohrenheilk.," p. 59. 



40 THE RESPIRATORY ORGANS. 

It is still an open question whether the tinnitus aurium 
which occasionally occurs in gradual changes of the 
external air pressure originates within the organ of hearing, 
or whether it is due to other causes. The subjective noises 
heard during balloon ascensions and mountain climbing are 
naturally attributed to the variations in pressure between the 
middle ear and the external air. But if we study the 
clinical picture of so-called mountain sickness, we are 
struck with the predominance of the circulatory phenomena, 
the markedly accelerated pulse, the dyspnea, and local 
symptoms of flashes and subjective noises in the ears ; we 
are irresistibly led to attribute the ocular and aural 
phenomena to the vascular disturbances, and not to alter- 
ations of the special sense organs. 

It may be well in this connection to call attention to the 
fact that similar phenomena, though somewhat milder in 
character, occur in the treatment of heart and lung diseases 
with rarefied and compressed air, when the patients are 
entering or leaving the pneumatic chamber. A certain 
degree of caution is therefore advisable in the case of in- 
dividuals whose hearing is not quite perfect, especially 
such as are troubled with tinnitus aurium. 

Schwartze's ^ observation that " many persons with 
incurable middle-ear sclerosis experience relief during a 
protracted stay in high Alpine health resorts, on account of 
their freedom from the distressing tinnitus aurium, and the 
marked improvement in the hearing " has not been ex- 
plained. But is it not permissible to assume that the aural 
symptoms are due to circulatory disturbances ? For if the 
tinnitus is really a vascular murmur within the ear, would 
it not be relieved by the beneficial effect of the altitude on 
the heart? 



DISTURBANCES OF THE FUNCTION OF THE EUSTACHIAN 

TUBE DUE TO ALTERATIONS IN THE UPPER 

AIR-PASSAGES. 

The diseases of the upper air-passages that diminish the 
permeability of the tubes are principally those which are 
accompanied by swelling of the mucous membrane. The 
relation existing between the nose and the postnasal space 
is a very intimate one, and very few diseases have their 

1 " Die chirurg. Erkr. des Ohres," p. 169. 



DISTURBANCES OF THE EUSTACHIAN TUBE. 4 1 

origin and exclusive seat in the postnasal space without in- 
volving the nose. The great majority of pharyngeal 
diseases arise, as we have already stated, by extension from 
the nose, so that the importance of rhinology in the study 
of diseases of the ear is easily explained. 

Any acute catmn^Ji in the upper air-passages may lead to 
intumescence and occlusion of the pharyngeal orifice, and 
thereby produce a fall in the pressure of the middle ear. 
As soon as the swelling subsides and the tube again 
becomes patulous, the morbid symptoms usually disappear 
without treatment. In chronic catarrh, on the other hand, 
as the hypertrophy of the mucous membrane does not, like 
the hyperemia in acute catarrh, tend to disappear sponta- 
neously, the changes produced in the middle ear by occlu- 
sion of the tube are of a more lasting character. The 
continued tension of the membrana tympani leads to 
atrophy, and the persistent retraction disturbs the normal 
relation of the ossicles, which then exert a constant pressure 
on the fenestra ovalis. 

It is fair to assume that, in consequence, the muscles of 
the ossicles — the tensor tympani and the stapedius — are 
thrown into a state of permanent contraction, and probably 
atrophy from disuse ; while, as a result of the hypercBinia ex 
vacuo, a chronic inflammation of the mucous membrane of 
the tympanum develops, giving rise to morbid conditions 
which can not be distinguished clinically from catarrh of the 
middle ear due to other causes. These conditions are in 
great need of anatomic and clinical investigation ; in fact, the 
concept of middle-ear disturbance by occlusion or obstruc- 
tion of the tube has never been clearly differentiated from 
the idea of inflammatory middle-ear catarrh, and the various 
views advanced in the text-books descriptive of middle-ear 
catarrh of inflammatory and noninflammatory origin merely 
add to the confusion. 

Any and all diseases of the nose and postnasal space 
which are followed by obstruction of the nasal passages lead 
to passive hyperemia in the mucous membranes, which in 
turn produces occlusion of the Eustachian canal. The 
recognition of this important fact is comparatively recent, 
and since the causal relation between these disturbances and 
the interference with nasal respiration by the presence of 
adenoid growths was definitely established the attention of 
clinicians has been directed to tlie significance of nasal 



42 THE RESPIRATORY ORGANS. 

Stenoses in occlusions of the Eustachian tube. The inter- 
ference with nasal breathing may be due to a number of 
conditions within the nose, as hypertrophy of the mucous 
membrane, mucous polypi, tumors, syphilitic or tuberculous 
infiltrations, foreign bodies, etc. There may be a congeni- 
tal narrowing of the nasal cavity from deformity, and hy- 
perplasia of the septum or abnormal curvature of the tur- 
binated bones. The obstruction may be situated in the 
postnasal space, and may take the form of hypertrophied 
pharyngeal tonsils, tumors, syphilis, or tuberculosis occlud- 
ing the posterior nares. Hence the recognition and re- 
moval of any obstacle to nasal respiration should constitute 
an integral part of every examination and treatment of the 
ears. There can be no hope of curing the ear affection be- 
fore the causes which are responsible for the congestion of 
the mucous membrane have been removed and the permea- 
bility of the tube has been restored. 

If I have included hypertrophy of tlie pharyngeal tonsils or 
adenoid vegetations among the diseases which produce hy- 
peremia and swelling of the mucous membrane, with occlu- 
sion of the tube by interfering with nasal respiration, it is 
because I believe the occlusion is due to a general " adenoid 
habit" of the nose and pharynx, rather than to the direct 
mechanical intrusion of the pharyngeal tonsil. The "ade- 
noid habit" manifests itself in the rhinoscopic image as a 
hyperplasia of the entire lymphatic ring of Waldeyer ; the 
follicles in the posterior pharyngeal wall and in the longitu- 
dinal folds on each side of the pharynx are more numerous, 
and are intensely red and swollen. Hyperplasia of Rosen- 
miiller's crypts and of the anterior fold of the tube may 
develop as the manifestation of a general hyperplasia of all 
the lymphatic elements entering into the formation of the 
so-called pharyngeal lymphatic ring ; hyperplasia of these 
structures necessarily favors the occlusion of the tube by 
compressing the orifice. 

Two forms of adenoid enlargement are distinguished : a 
diffuse, cushion-like hyperplasia, and a villous variety con- 
sisting of finger-like projections or true vegetations. Their 
usual seat is the roof and upper portion of the posterior 
wall of the pharynx, so that they fill the upper part of the 
postnasal space more or less completely, and whenever they 
hang down below the level of the upper margin of the 
posterior nares, the latter are obstructed and nasal breath- 



DISEASES OF THE MIDDLE EAR. 43 

ing is interfered with. As the vegetations usually spring 
from the median line, they are not, when at rest, in contact 
with the lateral walls of the pharynx and therefore do not 
occlude the orifices, as we are frequently able to demon- 
strate in the postrhinoscopic image ; but whenever the 
palatal and pharyngeal muscles contract, as in swallow- 
ing, retching, and similar movements, the lumen of the 
postnasal space is constricted and the enlarged growths are 
forced against the lateral walls of the pharynx, thus giving 
rise to periodic occlusion of the tube. The adenoid tissue 
is not the soft, gelatinous mass that it is sometimes com- 
pared to, but is comparatively firm, and returns to its 
normal position of rest, dependent on gravity, as soon as 
the constrictors of the pharynx and the tensores and leva- 
tores palati relax and the postnasal cavity regains its normal 
volume. But it is not clear to me how a momentary occlu- 
sion of the orifice can have the same effect as a permanent 
one, and I therefore consider the hyperemia of the entire 
mucous membrane the most important factor in the produc- 
tion of aural complications. 

Paralysis of the muscles of the soft palate, especially of 
the levator veli palatini and tensor veli palatini, — muscles 
which effect the opening of the Eustachian tube, — is fol- 
lowed by permanent occlusion, with the usual appearances 
of the membrana tympani. The action of the muscles may 
be similarly affected by tumors, by syphilitic, tubercular, or 
other kinds of ulcerations or their scars, and by cleft palate, 
so that these conditions are also occasionally accompanied 
by middle-ear disease. 



DISEASES OF THE MIDDLE EAR DUE TO INFECTION 
FROM THE POSTNASAL SPACE. 

The cartilaginous portion of the Eustachian tube is lined 
with ciliated columnar epithelium, the ciliary current being 
directed toward the pharynx, which is replaced at the isth- 
mus by cells of the same type as that of the middle ear. 
Since, therefore, the mucous membrane of the tube is a 
direct continuation of the epithelium of the postnasal space, 
we can readily understand that an inflammatory process 
beginning in the latter is not arrested at the pharyngeal 
orifice, but is continued into the tube itself, and may be 
followed by acute inflammation of the mucous membrane 



44 THE RESPIRATORY ORGANS. 

of the middle ear. Next to acute rhinitis and pharyngitis, 
the most important inflammations in the etiology of otitis 
media are those which occur in the aaite exanthemata. 
These will be discussed elsewhere. 

In addition to the ordinary inflammations of the mucous 
membrane of the tube and middle ear, we observe acute 
suppurative otitis media in the train of acute nasal and phar- 
yngeal diseases. As we may have either a simple or a 
suppurative inflammation without any apparent external 
reason, we are forced to assume a different behavior of the 
mucous membrane of the middle ear in regard to the in- 
vading pathogenic germs to explain the occurrence of sup- 
puration in the middle ear through the channel of the 
Eustachian tube. 

It is well known, as has been mentioned, that the nose and 
postnasal space harbor a multitude of microorganisms. 
Their presence in the healthy organism appears to have no 
significance, perhaps because of a bactericidal property of 
the mucous secretion which destroys the virulence of the 
pathogenic germs and prevents their further development. 
It may also be assumed — and has, in fact, been practically 
demonstrated experimentally by Zaufal, Kanthack, Scheibe, 
and others, in spite of the differences in the individual 
results — that the middle ear normally contains bacteria 
which may, under favoring circumstances, regain their vir- 
ulence. 

The number of bacteria in the middle ear and the liability 
of the organ to infection depend on the condition of the epi- 
thelium lining the tube and the size of the lumen. If the 
ciliated epithelium is intact, it enables the tube to rid itself 
of any deleterious substances, and thus forms a protection 
against invasions from the pharynx. Since any inflamma- 
tory alterations, be they acute or chronic, which destroy the 
integrity of the epithelium tend to remove this natural pro- 
tection, they will naturally be accompanied by inflamma- 
tion and suppuration in the middle ear. 

The question whether abnormal dilatations of the tube 
may produce pathologic conditions in the ear by affording 
an easier entrance to pathogenic germs deserves passing 
mention. 

In catheterization of the tube the nature of the blowing 
noise, and the strength of the concussion-note afford a clue 
to the size of the lumen. But, in addition to this, other 



DISEASES OF THE MIDDLE EAR. 45 

signs have been noted, depending on the respiration, which 
point to abnormal dilatation and permanent patulousness of 
the tube. 

Respiratory movements have been observed in the tympanic 
membrane by Lucae,i Schwartze,^ Wagenhauser, ^ and 
Ostmann ; * the membrane retracts during inspiration and 
bulges toward the external meatus in expiration. These 
observations were, however, always made on atrophic or 
cicatricially contracted membranes, which respond to a 
much slighter pressure than would a tense healthy mem- 
brane. According to Ostmann, it is sometimes possible, 
with the aid of a tube inserted into the external meatus, to 
hear an inspiratory and expiratory murmur, even in healthy 
individuals during quiet nasal respiration. Finally, Lucae's 
manometric experiments called attention to the occurrence 
o^ pressure valuations in the external auditory meatus synchro- 
nous with the respiratory movements. Ostmann, it is true, 
obtained varying results when he tried the same experiments; 
although he observed a constant variation of about ^ of a 
mm., synchronous with the pulse-beat, he could not demon- 
strate a constant coincidence with the respiratory move- 
ments. 

The first-mentioned phenomenon — respiratory move- 
ments of the tympanic membrane — is undoubtedly to be 
attributed to abnormal dilatation and permanent patulous- 
ness of the tube, while the second is of no value in the 
diagnosis of these conditions. 

Abnormal dilatation of the tube is practically a constant 
feature of atrophic catarrh of the nose and pharynx, 
rhinitis foetida atrophica, and these conditions are regularly 
accompanied by disease of the middle ear, either in the 
form of sclerosis of the middle ear or chronic suppurative 
otitis media. 

Sclerosis occurring in atrophic rhinitis is caused by a 
disease of the mucous membrane analogous to the dry 
catarrh of the upper air-passages. The histologic changes 
in otitis media sclerotica closely resemble those of "xero- 
sis " of the mucous membranes of the upper air-passages 
(Sticker), so that the middle-ear affection must be interpreted 
as a process analogous to atrophic rhinitis and pharyngitis. 
This was pointed out several years ago by Abel, when he 

1 " Arch. f. Ohr.," vol. il. 2 << ^rch. f. Ohr.," vol. 11 

3 " Arch. f. Ohr.," vol. xxi. ■* " Arch. f. Ohr.," vol. XXXIV. 



46 THE RESPIRATORY ORGANS. 

demonstrated his bacillus mucosus ozcenae in the middle ear, 
although that discovery seems to me to be of little import- 
ance, in view of the questionable connection between this 
bacillus and the development of ozena. 

It may be said that suppuration in the middle ear is 
principally due to the greater ease with which pathogenic 
germs can gain entrance when the tube is dilated, and to 
metaplasia of the epithelium. 

Ostmann ^ has called attention to another pathologic 
change at the pharyngeal orifice which may produce dilata- 
tion of the tube. The lateral wall of the tube is provided 
with a pad of fat, which normally acts as a natural protec- 
tion by facilitating the close application of the lateral to the 
median wall and thereby closing the tube. In emaciated 
individuals this pad is so much reduced that the tube is not 
perfectly closed, and there is a greater tendency to infection 
of the middle ear from the pharynx. Ostmann believes 
this to be the explanation of tubercular suppuration in the 
middle ear, which develops in phthisical patients when the 
general condition is weakened, and in the fourth or fifth 
week of typhoid, when the nutrition of the patient is much 
reduced. 

From a practical standpoint the infection of the middle 
ear through the introduction of infectious material into the 
tubes by therapeutic measures is extremely important. It 
may occur — by the current of air carrying mucus and pus 
from the nose, postnasal space, or orifice of the tube into 
the ear — during the performance of Valsalva's experiment 
or violent blowing of the nose with the nostrils closed, 
which has the same effect, and in Politzer's method of in- 
flating the tympanum, which consists in blowing air through 
one side of the nose while the nasopharynx is shut off from 
the oral cavity and the anterior nares are closed, so as to 
raise the air pressure in the postnasal space and force open 
the pharyngeal orifice of the Eustachian tube. Another 
danger of infection of the middle ear from the pharynx 
arises from the use of nasal douches in hypertrophic 
conditions of the nasal mucous membrane. As the 
water enters the nasal cavities under considerable pressure, 
and can not escape through the nose on account of the 
swelling of the membrane, it is dammed up in the postnasal 

^ "Arch. f. Ohr.," xxxiv, p. 188, etc. 



THE EARS. 47 

space, and being under pressure, easily makes its way into 
the middle ear. This is, therefore, an example of the im- 
proper use of the nasal douche, being in violation of the 
principle that the use of a nasal douche with low pressure is 
permissible only when both sides of the nose are sufficiently 
open to allow free access to and egress from the nose. Even 
when this rule is carefully observed there is a possibility of 
water reaching the middle ear, if during its passage the 
patient swallows or chokes, or performs a similar act which 
opens the Eustachian tubes and facilitates the entrance of 
the fluid into the middle ear. ^ 

But as, in spite of the frequency of these harmful condi- 
tions and the presence of infectious mucus in the upper 
air-passages, infection of the middle ear takes place only 
occasionally and in certain cases, it is evident that the de- 
velopment of pathogenic germs is determined more by a 
favorable condition in the ear itself than by the fact of their 
gaining entrance through the tube. Such a condition is 
produced chiefly by acute inflammations of the mucous 
membrane, and we expect to find suppuration of the middle 
ear in acute coryza, in the acute exanthemata which are 
accompanied by rhinopharyngitis, and in the acute inflam- 
mation which follows the use of the galvanocautery in the 
nose ; and we can not emphasize too strongly that air 
douches, as well as the ordinary nasal douche, are to be 
avoided in acute disease of the nose and throat with inflam- 
matory changes in the Eustachian tubes. 



4. THE EFFECT OF VARIOUS DISEASES OF THE 
RESPIRATORY ORGANS ON THE EARS. 

Pain in the cars or pain radiating from the neck to the ears 
is a symptom occurring in a great variety of diseases of 
the upper air-passages. It occurs with the greatest regu- 
larity in all inflammatory diseases of the epiglottis and 
upper margin of the larynx which are accompanied by 
swelling, and is met with also in malignant tumors of the 

' The rule which obtains in our country — viz., to introduce the tip of the 
nasal douche only into the side of the nose most obstructed, to allow free 
exit of the fluid from the more open side — would seem an important sugges- 
tion. — Ed. 



48 THE RESPIRATORY ORGANS. 

larynx and upper portion of the esophagus. The physi- 
cian sees many cases of tuberculosis with infiltration and 
ulceration of the mucous membrane covering the cartilages, 
and perichondritis of the epiglottis and arytenoid and 
cricoid cartilages, in which the patients complain of violent 
pain radiating to or localized in the ear. The pain is in- 
creased by any pressure or movement in the affected region, 
and usually attains its maximum intensity during the act of 
swallowing, making it very difficult to feed the patient 
properly. The greatest distress is usually complained of 
when the patient invoknitarily goes through the act of 
swallowing, just as in any form of angina, and especially in 
tonsillar abscess, while the swallowing of slimy, semisolid 
food is a little less painful. 

In carcinoma of the larynx pain radiating to the ears is 
practically a constant symptom ; it is usually of a paroxys- 
mal character, like the lancinating pain of neuralgia. In 
the early stages of the growth the pain is dull and localized 
in the larynx, but radiates to the ears when the ulcerative 
stage is reached. ^ 

Since the sensory nerves at the entrance to the larynx 
and in the deeper portions of the pharynx are branches of 
the vagus, and the external auditory meatus receives 
sensory fibers from the same trunk through the auricular 
nerve, the vagus must be the channel by w^hich these reflex 
pains are transmitted. The reflex arc is very well devel- 
oped, as is shown by the fact that irritation of the sensory 
filaments of the auricular nerve of the vagus in the external 
meatus — as, for instance, when a speculum is introduced — 
often brings on a fit of coughing. 

Our information in regard to the relation existing between 
croupous pneumonia and purulent otitis media is not very 
definite and lacks clinical confirmation ; it amounts to this : 
suppuration in the middle ear is rare after croupous pneu- 
monia, presents no distinct type, and its course is not 
different from that of any other form of purulent otitis 
media. In severe cases of pneumonia with high fever the 
tympanic membrane is found to be injected without exuda- 
tion taking place, just as in other infectious fevers, especially 
typhoid. Again, as in other diseases characterized by great 

1 Comp. Fauvel, " Traite pratique des malad. du larynx," 1876, p. 707. 



THE EARS. 49 

elevation of temperature, a chronic suppuration may tem- 
porarily subside during the fever, and the perforated 
membrane and mucosa of the tympanum appear dry and 
dark red in color ; but there is no reason to suppose that 
these phenomena have any specific relation with the pneu- 
monia. 

Acute suppuration in the middle ear is occasionally pro- 
duced by the diplococcus pneumoniae of Frankel-Weichsel- 
baum. Netter,! as early as 1890, called attention to the 
frequent occurrence of the pneumococci in the pus found in 
the ears of little children at autopsies, and his findings have 
been confirmed by Rasch,^ who found the pneumococci of 
Talamon-Frankel in the ear secretion of 33 out of 43 cases 
examined by him ; he also comments upon the remarkable 
fact that these exudations are practically never accom- 
panied by perforation of the tympanic membrane. Zaufal ^ 
says there are ear-diseases " which run a strictly pneumonic 
course ; they are ushered in with a chill, the temperature 
falls, and recovery takes place by crisis on the seventh or 
eighth day." This observation of Zaufal led Haug '^ and 
Brieger ^ to "assume a strictly pneumonic character and 
course for otitis due to diplococcus infection," or at least to 
point out the similarity " evidently existing in many particu- 
lars between genuine pneumonia and acute purulent otitis 
media." If they had read two lines further in Zaufal' s 
article they would have seen that he considers it practically 
certain " that otitis due to streptococcus infection may run 
exactly the same course." When it is remembered that the 
diplococcus pneumoniae is simply a pathogenic organism 
which does not produce pneumonia exclusively, and may 
give a general septic infection in no way distinguishable 
from that produced by other pyogenic organisms ; and 
when, on the other hand, it is considered that diplococci 
are constant inhabitants of the upper air-passages in the 
healthy body, and can easily reach the middle car and set 
up a suppuration if the condition of the mucous membrane 
is favorable, just like any other pathogenic organism that 



1 " Comptes rendus de la soc. de biolog.," iSgo. 

2 " Jahrb. f. Kinderheilk.," xxxvn, p. 32S e^ se//. 
^ " Arch. f. Ohr.," xxxi, p. 184 ^/ si-i/. 

*" Die Kranklieiten des Olires," etc., p. 50. 
5 <' Klin. ]5eitrage zur Ohrenbeilk.," p. 68. 



50 THE RESPIRATORY ORGANS. 

may be constantly present in the air-passages, it is well- 
nigh incredible that the mere fact of this organism playing 
a certain not thoroughly understood role in croupous pneu- 
monia, and setting up a suppuration in the middle ear, 
should be utilized as a base on which to rear, with infinite 
art and ingenuity, the edifice of an entirely new disease, 
under the name of "pneumonic otitis media.'" 

Wreden ^ maintains that disease of the ear may be 
caused hy atelectasis, bronchiectasis, 2X\.(\ capillary broncliitis ; 
citing in explanation Lucae's observation that under normal 
conditions there is a regular pressure variation synchronous 
with the respiration. Believing, with Lucae, that the mid- 
dle ear is in this way ventilated with every respiration, he 
concludes that the ventilation is insufficiently performed 
whenever the respiration is impaired, and consequently any 
disease which is attended with reduction of the respiratory 
function may be followed by disease in the ear. 

We have already said enough on this subject to show 
that we consider these opinions as disposed of, but Wreden 
must nevertheless be given credit for having pointed out 
the frequency of ear anomalies observed at the autopsy in 
infants about a year old who died of pneumonia, presumably 
the catarrhal form. Later, Rasch '-^ examined the bodies 
of 43 children dead of bronclwpneiimonia, and in 42 in- 
stances found inflammatory conditions in the ears, which in 
30 consisted in middle-ear suppuration ; while Ponfick,^ in 
10 out of 1 1 cases of uncomplicated pneumonia, found 
middle-ear suppuration at the autopsy, the ages ranging 
from one month to four years. In the absence of more 
convincing information, especially of a clinical nature, the 
question whether catarrhal pneumonia is the real cause of 
the suppuration must remain undecided. In the present 
state of our knowledge it seems more likely that the child- 
ish organism is predisposed to suppuration of the middle 
ear by any disease which seriously interferes with its nu- 
trition, whether it be catarrhal pneumonia or any other 
affection. Later on we shall study the significance of intes- 
tinal affections in the production of ear diseases in young 
infants, and shall then learn that occasionally nutritive dis- 
turbance, by its weakening effect on the general resisting 

1 " Mon. f. Ohr.," 1S68, p. 105 et seq. 2 Loc cit. 

3 " Berl. klin. Wochen.," 1897, p. 852. 



THE EARS. 5 I 

power of the infantile organism, is the predisposing cause of 
the aural complication. 

The possibility of infection in the opposite direction de- 
serves passing mention. Bronchitis and bronchopneumonia 
occasionally develop after purulent otitis media by aspira- 
tion of particles of pus and the contained bacilli which have 
found their way into the pharynx from the middle ear. 



II. DISEASES OF THE CIRCULATORY 
SYSTEM. 



L DISEASES OF THE HEART AND BLOOD-VES- 
SELS IN THEIR RELATION TO THE NOSE, 
PHARYNX, AND LARYNX. 

Diseases of the heart and blood-vessels lead to — 

1. Circulatory disturbances in the mucous membranes 
of the upper air-passages, producing hemorrhages, hyper- 
emia, and congestive catarrh. 

2. Motor disturbances by direct injury to the laryngeal 
nerves which are situated in their immediate neighborhood. 

3. Pulsation of the large arterial trunks, when they are 
diseased, is transmitted to various portions of the upper 
air-passages. 

4. Aneurysm of the aorta may lead to stenosis of the 
trachea or rupture into that tube. 

Hemorrhages from the mucous membranes of the upper 
air-passages constitute a frequent concomitant of cardiac 
disease without compensation, and occur also, in conse- 
quence of the rise of arterial pressure, when compensation 
exists ; they are most common in venous stases due to failure 
of compensation in mitral disease and in aortic insuffici- 
ency. They are also observed in arteriosclerosis, and 
Edgren ^ reports the occurrence of epistaxis " during the 
presclerotic period, at a time when the only recognizable 
symptom is a heightened arterial pressure " ; he considers it, 
when occurring in elderly persons without apparent cause 
or after violent emotion, a symptom of incipient arterio- 
sclerosis. The attacks soon cease to appear, even when 
they have been severe at one time. During the later stages 
of arteriosclerosis "the attacks 6f epistaxis appear to dimin- 
ish in frequency, probably because of lowered blood pres- 
sure and lessened cardiac activity " (Edgren). 

1 "Die Arteriosklerose," Leipzig, 1898. 
52 



THE HEART AND BLOOD-VESSELS. 53 

Epistaxis is the commonest form of bleeding from the 
mucous membranes ; hemorrhages from the pharynx and 
larynx are rare. Although the usual, one might almost 
say the constant, seat of epistaxis is the spot known as 
locus Kieselbachii, on the cartilaginous portion of the sep- 
tum, — recognized by the greater density of the vascular 
plexus, — the hemorrhages which occur in general circula- 
tory disturbances often appear to originate in the lateral 
walls, and especially in the cavernous tissue. It is, unfor- 
tunately, impossible to locate the bleeding point while the 
hemorrhage continues, and even after the bleeding has 
stopped it is not always possible to determine its origin, on 
account of the hyperemic condition of the nasal mucous 
membrane and the presence of blood-clots. Hemorrhages 
have been reported from the veins at the base of the tongue, 
which sometimes become enormously engorged in condi- 
tions of passive hyperemia, and Compaired ^ mentions 
hemorrhage from the plexus on the glosso-epiglottidean 
fold in mitral insufficiency. 

The hyperemia in course of time gives rise to congestive 
catarrh, involving the entire mucous membrane of the 
upper air-passages, and presenting the symptoms and clin- 
ical appearances seen in chronic rhinitis, pharyngitis, and 
laryngitis. The recognition of the symptoms of these 
forms of chronic catarrh is important, as it materially affects 
the treatment. Local measures are, of course, little 
•adapted to effect a cure ; painting with silver nitrate solu- 
tion, which for some reason is such a favorite mode of 
treatment, is absolutely useless as long as constitutional 
treatment is neglected. 

Passive edema in the larynx is a late complication, which 
does not develop in heart disease until failure of compen- 
sation has led to general edema ; it therefore has no great 
value in diagnosis, as the local symptoms at this period are 
always overshadowed by the general phenomena.^ 

The paralyses which occur in the course of cardiac and 
vascular disease find their explanation in the proximity of 
the recurrentnerves to the great vessels in the mediastinum. 
The inferior laryngeal nerve is a branch of the pneumogas- 

' " Ann. des maL de I'oreille," 1896. p. 470. 

^ In "Arch. f. Laryng.,',' vol. vni, No. 3, v. Sokolowski gives a descrip- 
tion of the "morbid changes in the upper portion of the respiratory tract in 
the course of valvular disease." 



54 THE CIRCULATORY SYSTEM. 

trie, arising in the mediastinum, and, as its name — recurrens 
— implies, running back and upward to the larjmx. The 
two nerves follow a different course^ and therefore come 
into relation with different structures on the two sides of 
the body. The left nerve winds around the aorta and 
ascends along the posterior margin of the lateral wall of the 
trachea, in the groove between it and the esophagus, to 
reach the larynx ; the right arises from the vagus at the 
level of the subclavian artery, winds around this vessel from 
before backward, and follows a course between the trachea 
and esophagus similar to that of its fellow. 

The commonest causes of disturbances in the upper air- 
passages are found in dilatations of the great vessels, due to 
aneurysm. The most important are the aneurysms of the 
aorta, the symptoms of which require a detailed description. 
They consist in paralysis of the recurrent by direct injury 
to the nerve ; transmitted pulsation of the larynx and 
trachea ; tracheal stenosis from displacement of the wall of 
the trachea ; and, lastly, rupture of the aneurysmal sac into 
the trachea. 

Since the left recurrent nerve is in contact with the entire 
circumference of the acch of the aorta, it is affected by any 
aneurysm exerting pressure or traction on that structure. 
Traube ^ was the first to describe a paralysis of the recur- 
rent due to aneurysm of the aorta, and since his day in- 
numerable similar cases have been reported, so that paraly- 
sis of the left vocal cord has become one of the most 
important symptoms in the diagnosis of aneurysm of the 
aorta. 

Paralysis of the recurrent nerve — a term by which, 
as will be more fully explained in treating of diseases of 
the nerves, is meant complete paralysis of all the muscles 
supplied by the inferior laryngeal nerve, the adductors as 
well as the abductors — is a typical symptom of aneurysm 
of the aorta, and, on account of the peculiar hoarseness it 
produces, rarely escapes the notice of either the doctor or 
the patient. It is quite different with the other form of 
paralysis of the recurrent, which affects only the cricoary- 
tcxnoideus posticus, and exerts but little influence on either 
phonation or respiration, so that for several reasons it is not 
often observed in aneurysmal disease. It represents the 

1 " Deutsche Klinik," i860, No. 41. 



THE HEART AND BLOOD-VESSELS. 55 

early stage of paralysis, and may be present when the 
aneurysm is beginning to develop, before any clinical 
symptoms have made their appearance. As this form of 
paralysis produces no functional disturbances, it escapes the 
notice of the physician, unless it is accidentally discovered 
in the course of a laryngoscopic examination. 

It is owing to these two facts — the gradual, and at first 
painless, development of the aneurysm and the absence of 
symptoms in paralysis of the posticus — that the disease 
does not, as a rule, come under observation until it has 
made considerable progress, and the change from the 
median to the cadaveric position, which is the outward sign 
of paralysis of the recurrent, has taken place. Among 
other motor disturbances in the larynx in aneurysms of the 
aorta may be mentioned laryngospastic attacks and periodic 
palsies of the vocal cords. Lori and Grossmann have de- 
scribed certain laryngeal disturbances which are rarely 
observed as symptoms of incipient aneurysm of the aorta. 
Lori 1 says that the pressure of the aneurysm on the re- 
current nerve in some cases provokes transient motor 
phenomena in the muscles of one-half of the larynx, which 
manifest themselves in difficult articulation ; in hoarseness, 
occurring at frequent intervals and without discoverable 
cause ; in sudden changes of the voice or of a single note ; 
and occasionally in spasm of the vocal cords. These 
phenomena, however, which are due to the irritation of very 
slight pressure, according to Lori, are replaced after a few 
days or weeks by paralysis of the entire half of the larynx 
from the increased pressure on the recurrent nerve. 

In agreement with Lori, Grossmann explains similar 
phenomena observed by him as the effect of irritation by 
the gradually increasing pressure of the aneurysm on the 
nerves. His case ^ is remarkable from the fact that he 
was able to observe it more than a year. The patient came 
to be treated for frequent attacks of dyspnea of short 
duration, before there was any suspicion of aneurysm. 
After one of these attacks Grossmann observed a " paraly- 
sis of the left vocal cord," which disappeared on the follow- 
ing day. A few days later there was another attack of 
dyspnea, also accompanied by " total left-sided paralysis 

'"Die diirch Allgemeinerkrankung Ijewirkten anderweitigen Veninder- 
ungen," etc., p. 61. 

2 " Arcli. f. I.aryng.," vol. 11, p. 254. 



56 THE CIRCULATORY SYSTEM. 

of the vocal cord." It is not quite clear from the descrip- 
tion whether we have here a paralysis of the posticus or of 
the recurrent. One year later unmistakable clinical symp- 
toms of aneurysm had developed, and, with the appearance 
of a total left-sided paralysis of the recurrent, the laryngo- 
spastic attacks ceased. 

We have so far confined ourselves to the effects of pres- 
sure on the left inferior laryngeal nerve by an aneurysm of 
the aorta. The explanation of those cases, first described 
by Gerhardt ^ and Baumler,^ in which left-sided paralysis 
of the recurrent is combined with a similar paralysis on the 
right side, or in which there is right unilateral paralysis of 
the vocal cords, presents greater difficulties, as the course 
of the right recurrent nerve does not make the occurrence 
of such a condition appear probable. Among similar cases 
may be quoted Onodi's,^ in which the right vocal cord 
was fixed in the cadaveric, and the left in the median posi- 
tion, and Cartaz's case, in which there was marked dyspnea 
and both vocal cords were seen in the median line, two or 
three millimeters apart, immovable, with concave edges. It 
is remarkable how often Lori * found the right nerve in- 
volved ; he reports three cases of paralysis of the right half 
of the larynx and two cases of bilateral paralysis. Baum- 
ler gives as an explanation of his case that the aneurysm 
produced overfilling, or even an aneurysmal dilatation, in 
the right subclavian artery, or that it pressed on the nerve 
from below at its origin from the pneumogastric. Another 
explanation appears to me to be suggested by the fact that 
unilateral paralysis of the pneumogastric is capable of pro- 
ducing bilateral disturbances of mobility. Semon,^ and 
before him Lori,^ gives the following explanation : A 
peripheral stimulus of the pneumogastric is transmitted 
through the afferoit fibers of that nerve to the center in the 
medulla ; from there it passes into the two motor nuclei of 
the vagus (Semon calls them the accessory nuclei), and 
thus gives rise to a bilateral disturbance of motility (John- 
son's theory '^). 

Aneurysms of the aorta ultimately produce changes in 



" Virch. Arch.," xxvn, p. 75. 2 « Arch. f. klin. Med.," Ii, p. 550. 

" Semon's Centralbl.," X, p. 429. 

" Semon's Centralbl.," vni, pp. 35S and 493. ^ Loc. cif., p. 62. 

Heymann's " Handb. der Laryng.," I, p. 615. 

Semon quotes " Med. Chir. Trans.," vol. Lviii, 1875. 



THE HEART AND BLOOD-VESSELS. 57 

the trachea ; pulsating movements, which may extend to the 
larynx ; tracheal stenoses by compressing the walls ; and, 
finally, pressure nlcers and perforations. 

The arch of the aorta curves over the left bronchus from 
before backward, and lies close to the left anterior aspect of 
the trachea, just above the bifurcation, so that it occupies 
the obtuse angle formed by the trachea and left bronchus. 
Even under normal conditions a movement can be observed 
in the spur of the trachea in the laryngoscopic image, 
caused by the transmitted pulsation of the aorta. When 
the arch and descending limb of the aorta are dilated by an 
aneurysm and brought into closer contact with the trachea, 
the pulsation is communicated to the entire trachea, and can 
be observed even in the larynx. Oliver suggests bending 
the patient's head back, so as to draw the larynx upward, 
for the purpose of bringing out tracheal pulsation, while 
Cardarelli ^ observes the pulsation by the movements of 
Adam's apple with the patient's head bent back, and even 
pretends to be able to diagnose the seat of the aneurysm by 
the oblique direction of the pulsating movements. 

Compression of the windpipe by an aneurysm in most 
cases produces a so-called scabbard-like stenosis of the 
trachea on the left side, with stenosis of the left bronchus. 
When the aneurysm is in the ascending limb, or in the arch, 
the pressure may in rare cases be exerted on the right side 
of the trachea and on the right bronchus. It is important 
to recognize these tracheal stenoses, as the respiratory em- 
barrassment might otherwise be attributed to paralysis of 
the vocal cords which is usually present at the same time. 
Tracheotomy under such circumstances is, of course, use- 
less ; even the introduction of a cannula to the bifurcation, 
beyond the seat of the stenosis, gives only a temporary 
relief, because the pressure of the cannula very soon pro- 
duces decubital ulcers in the trachea, through which rupture 
of the aneurysm takes place. 

The rupture of an aneurysm into the trachea or bron- 
chus is not a rare occurrence, but the mechanism has been 
variously explained by different anatomists. Eppinger ^ 
believes that the tracheal rings are forced apart by the wall 
of the aneurysm, and that rupture takes place through 
secondary aneurysms which form between the separated 

1 "Centralbl. f. inn. Med.," 1894, No. 42, p. 988. 

2 Klebs, " Handb. der pathol. Anatomic," VH, p. 270 ct seq. 



58 THE CIRCULATORY SYSTEM, 

rings. He saw no proliferation of the cartilage or ulcera- 
tion of the mucous membrane: "The edges around the 
seat of rupture were turned toward the interior of the 
trachea, and regularly sharp or delicately serrated and scaly, 
just as in true traumatic ruptures." Other authorities have 
described " conversion of the cartilage into detritus in con- 
sequence of compressing aneurysms, and atrophy of the 
cartilage by a process of fatty degeneration." ^ Accord- 
ing to Selter,^ who examined five cases, ulcers form in the 
mucous membrane as a result of the pressure, and subse- 
quently lead to rupture of the aneurysms into the trachea 
or bronchus, so that the rupture is prepared from without. 

In rare cases, paralysis of the vocal cords follows disease 
of other arterial trunks. Selter ^ saw an aneurysm of the 
innominate artery with paralysis of the right recurrent ; 
E. Meyer ^ describes the same lesion in aneurysm of the 
right subclavian artery ; in another case, marked pulsation 
in the pharynx was referred to aneurysmal dilatation of the 
carotid. 

A pericardial exudate sometimes gives rise to paralysis of 
the left recurrent. Baumler * first pointed out that the 
same condition can also produce paralysis of the right re- 
current. " If the exudate is very abundant, and distends 
the pericardium as far as the jugular notch, the engorge- 
ment of the veins which meet at that point may exert 
direct or indirect pressure on the right recurrent." The 
case he quotes, which seems to me entirely convincing, has 
been called in question by Landgraf,^ because the autopsy 
showed some slight syphilitic alterations in the larynx. 

The paralysis attains its greatest intensity at the height of 
the exudative process, and subsides with the pericarditis. 
In this respect Landgraf 's case is instructive : a pericar- 
dial effusion developed after articular rheumatism, and 
produced at first a paralysis of the posticus in the median 
position, which developed into paralysis of the recurrent in 
the course of the next two weeks, but the paralysis disap- 
peared when the primary disease was removed. 

Palpitation of the heart is one of the reflex neuroses, due 

^ Klebs. " Handb. der pathol. Anatomic," vii, p. 270 et seq. 
-"Virch. Arch.," 133 ; also comp. D. Gerhardt, " Virch. Arch.," 123, 
p. 201. 

3 "Arch, f, Laryng.," II, p. 263. 

* "Arch. f. klin. Med.," 11, p. 550 et seq. 

5 " Charite Ann.," XIII, 



THE EAR. 59 

to irritation in the nose. It occurs in chronic rhinitis with 
hypertrophy and polypus formation, and sometimes takes 
the paroxysmal form, analogous to sthenocardiac attacks 
and cardialgia. An interesting phenomenon, which has not 
as yet been satisfactorily explained, is sudden death from 
heart failure, which sometimes takes place a few days after 
extirpation of the larynx. Stork ^ attributes the phenom- 
enon to injury of a depressomotor branch of the superior 
laryngeus, which is not constantly present ; Grossmann ^ 
thmks it is caused by a central irritation of the superior 
laryngeal or of the vagus during the operation, while Toti^ 
reports, without explaining, a case in which acceleration of 
the pulse rate to from i6o to i8o occurred thirty hours 
after an operation for the total extirpation of the larynx ; 
and after twenty-four hours more of uninterrupted tachy- 
cardia the patient died of cardiac paralysis. 



2. DISEASES OF THE HEART AND BLOOD- 
VESSELS IN THEIR RELATION TO 
THE EAR. 

Tinnitus aurium is a frequent symptom of disease of the 
heart and blood-vessels and of anemia or hyperemia of 
the vascular systems within the ear. Our knowledge of 
these conditions is unfortunately very scanty, and we are 
hardly more advanced than w^as v. Troltsch twenty years 
ago, when he wrote : " There is no doubt that tinnitus 
aurium is much oftener due to vascular murmurs than the 
profession has been inclined to believe up to the present time, 
as we are in the habit of attributing them chiefly to the in- 
fluence of the nervous apparatus. It is often impossible to 
decide which of the two varieties is present, and simulta- 
neous processes in both the circulatory and the nervous 
apparatus are probably of still more frequent occurrence." 

Before proceeding to the discussion of pathologic changes, 
let us direct our attention for a moment to the normal con- 
ditions in which we do not observe any vascular murmurs. 
Since Weil ^ could hear the heart-sounds communicated to 

1 " Wien. med. Wochen.," i8S8 ; and Alpiger, "Langenb. Arch.," xl. 

2 "Wien. med. Presse," 1892, Nos. 44-46. 
■'" Deutsche med. Wochen.," 1S93, p. 87. 

■^ " Die Auscultation der Arterien u. Ventn," 1S75. 



60 THE CIRCULATORY SYSTEM. 

the blood stream as vascular murmurs by auscultation of 
the carotid in the neck, it might be supposed that they could 
be equally well heard over the internal carotid where it 
passes through the canal in the petrous portion of the 
temporal bone. The solid bone which lodges the labyrinth 
is excellently adapted to conduct the sound to the internal 
ear, and the position of the carotid near the anterior wall of 
the tympanum would appear to render its perception very 
easy. The fact that the sound is not heard appears to be due 
to the venous plexus which surrounds the artery within the 
carotid canal, and acts like a cushion to arrest the pulsations 
and soften the sound. 

The sinus of the jugular vein lies beneath the cavity of 
the tympanum ; and unless there are venous murmurs, there 
can not be any sound transmitted to the ear. 

The ear itself is provided with two systems of blood- 
vessels — one in the middle ear and one in the internal ear. 
The former is composed of various branches derived from 
the external and internal carotids ; the latter belongs to the 
internal auditory artery, a branch of the basilar. To the 
investigations of Eichler ^ and Siebenmann^ we owe our 
knowledge of the distribution of the capillaries in the 
neighborhood of Corti's organ. It was found that the 
membranes of Reissner and Corti, as well as that portion of 
the zona pectinata contained between the external pillar and 
the ligamentum spirale, are quite free from blood-vessels, 
and therefore the sensitive terminal apparatus of the 
auditory nerve is as far as possible removed from the 
influence of the vascular system. 

It follows, therefore, that since, in spite of the proximity 
of the great vessels, the healthy ear does not perceive 
vascular murmurs, one of two pathologic possibilities must 
account for the occurrence of vascular noises : there must 
be disease either of the organ of hearing or of the vascular 
system. 

In the former case the pathologic changes in the organ of 
hearing bring about more favorable conditions for the per- 
ception of the normal blood murmurs ; either the sound is 
more readily conducted on account of alterations in the 

1 " Die Wege des Blutstroms iin menschl. Labyrinth," " Abhandl. der 
math. phys. CI. der kgl. sachs. Gesellsch. der Wissensch. ," vol. xviii, No. 5, 

P- 327- 

2 See " Handb. der Anatomie," edited by v. Bardeleben, vol. v, part 2. 



THE EAR. 6 I 

bone or the presence of an exudate, or the irritability of the 
auditory nerve is heightened, so that noises which before 
were below its range of hearing are now appreciated by the 
sensory end-organs. The quality of this kind of tinnitus 
aurium, which must be included under the general head of 
entotic vascular murmurs, is not as yet sufficiently known 
to make a classification into definite types possible. The 
different characters of an arterial and a venous murmur, as 
they have been described, and the interruption of the sound 
by compression of the respective artery or vein are not 
constant symptoms and can not be utilized in making a 
diagnosis. We shall return to this subject in another place. 

The second group of subjective noises observed in dis- 
eases of the heart and blood-vessels are due to the trans- 
mission of abnormal vascular murmurs to the healthy ear. 
Among these we must distinguish those which originate in 
the heart and those which begin in the vessels. 

To the former class belong the noises heard in valvular 
disease and in aneurysm, in which blowing, breathing, and 
hissing sounds are often heard in the ear and described as 
pulsating, hammering, or knocking noises. These descrip- 
tions are so common as to arouse the suspicion that the 
patient is describing a sensory perception of the arterial 
pulse, and not a true tinnitus aurium. Such a confusion of 
sensory perception of periodic movements with auditory 
impressions is much more probable than appears at first 
sight ; it is often met with to an astonishing degree in test- 
ing with the tuning-fork. Just as the patient who is not 
used to observing accurately distinguishes with difficulty 
between the zdbrations imparted to the entire head by a fork 
of low pitch and the tone of the fork transmitted to the ear 
over the craniotympanic conducting arc, so he may be mis- 
led by the sensation of the arterial pulse, and interpret it as 
an auditory impression, for we observe these hammering 
and knocking noises whenever the cardiac activity is height- 
ened. Any one can " hear " the beating of his heart after 
physical exertion or mental emotion, but he can not say 
with certainty whether the impression is due to cardiac or to 
vascular murmurs. The theory that what is perceived by 
the patient in heart disease is not the valvular murmur, but 
rather the heightened arterial pulsation due to increased 
cardiac activity, finds further confirmation in the observation 
that these " entotic vascular murmurs " are complained of 



62 THE CIRCULATORS SYSTEM. 

particularly in aortic regurgitation with its rapid pulse, 
which produces an arterial pulsation that is perceptible even 
in the capillaries. 

The murmurs which originate in the vessels themselves 
are produced by eddies in the blood stream, not by any 
special action of the vessel walls. The most important 
predisposing causes are the size of the lumen and the elas- 
ticity of the vessels. 

It appears from reports of cases, some of which will be 
given later, that entotic vascular murmurs, whether of 
arterial or of venous origin, are observed with great fre- 
quency in aneurysm, in anemia and chlorosis, and in 
arteriosclerosis ; they occur as the result of circulatory dis- 
turbances in general plethora, in alcoholism, and after 
intoxications which are followed by a rise in blood pressure, 
or vasomotor paralysis, especially after the abuse of tobacco, 
and after full doses of quinin and salicylic acid. In this 
class belong the vasomotor disturbances with tinnitus 
aurium which occur in paralysis of the sympathetic, in 
connection with hyperemia of the skin ; they represent a 
symptom of Basedow's disease, which, according to Mobius, 
must now be regarded as an intoxication depending on the 
loss of the function of the thyroid gland, and not, as was 
formerly supposed, as a disease of the sympathetic system. 

Finally, there are subjective noises which occur after 
zvotmds of the head in connection with partial loss of hear- 
ing and vertigo ; they are usually attributed to vasomotor 
irritation. As these symptoms are usually observed only 
in cases of accidents, there is a natural tendency to ascribe 
them to traumatic hysteria and neurasthenia. This is the 
view adopted by Schwartze some time ago ; but Miiller, ^ 
in a recent communication from Trautmann's clinic, pointed 
out that a wound of the head may give rise to irritation of 
the vasomotor center, manifesting itself first in contraction 
and later in relaxation and paralysis of the muscular walls 
of the blood-vessels ; this may in turn be followed by 
extravasations and permanent functional disturbances which 
explain the subjective symptoms complained of by the 
patient. The tinnitus aurium in this case is, therefore, 
to be regarded as the result of hyperemia manifesting 
itself at first in hyperemia of the tympanic membrane and 

1 "Deutsche med. Wochen.," 1898, No. 31. 



THE EAR. 63 

external auditory meatus, which later may be replaced by 
cloudiness of the membrane. 

The investigations in arterial auscultation by Weil ^ and 
V. Frey ^ show that the blood-vessels give forth a peculiar 
note, rarely heard in healthy individuals, but frequently in 
fever patients, in anemia and chlorosis, and in aneurysm ; on 
the other hand, according to Weil's observations on the 
femoral artery, the tone was persistently absent in condi- 
tions of high arterial tension from atheromatosis and nephri- 
tis with hypertrophy of the heart. In the former case the 
results of auscultation coincide with the subjective ear 
symptoms, while in the latter the frequent occurrence of 
entotic vascular murmurs in arteriosclerosis is in marked 
contradiction to them. But we find an explanation for the 
occurrence of tinnitus aurium in atheromatosis in the in- 
vestigations of Nolet,^ who found that murmurs in the 
vessels may be caused by sudden changes in the pressure 
and velocity of the blood wave, such as are produced by 
changes in the lumen of the vessel. These conditions are 
most marked in arteriosclerosis when there are aneurysmal 
dilatations in the vessels. The behavior of the blood-vessels 
of the ear in arteriosclerosis has, unfortunately, never been 
examined anatomically, but it is safe to say that the pro- 
duction of entotic murmurs depends on the extent of ather- 
omatous change and the presence of miliary aneurysmal 
dilatations ; a unilateral tinnitus aurium, therefore, does not 
necessarily exclude an atheromatous origin, but merely 
suggests the existence of a local form. Stacke'^ reports a 
case characterized by the perception of marked subjective 
tones, high in pitch, combined with central deafness of the 
right ear ; he explains the unilateral character of the symp- 
toms by the existence of a circumscribed atheromatosis of 
the vessels in the right side of the neck. 

Being convinced of the frequency of tinnitus aurium as a 
concomitant of arteriosclerosis, I examined for this symp- 
tom the 124 case histories of arteriosclerotic patients 
reported by Edgren,^ but to my astonishment I found 
such complaints in only three of the histories, although 
Edgren himself remarks further on (p. 207) that vertigo and 

^ " Auscultation der Arterien u. Venen," 1875. 

2 V. Frey, " Die Unteisuchung des Pulses," 1892, p. 6 et seq. 

3 "Arch. d. Heilkunde," 1S71. * "Arch. f. Ohr.," xx, p. 286. 
5 " Arteriosklerose," Leipzig, 1S98. 



64 THE CIRCULATORY SYSTEM. 

tinnitus aurium are complained of early in the disease by 
many patients. His interpretation of these complaints 
differs somewhat from my own views ; he finds the cause of 
the noises "in the brain," and attributes them simply to in- 
creased arterial tension, without any material alterations in 
the brain itself. 

I shall now proceed to quote a few cases of subjective 
noises in the ear. Moos ^ reports a case in which the 
noises were very loud and compared by the patient to the 
noise of machinery and railroad trains ; at the autopsy the 
sinus of the jugular vein was found abnormally dilated. 
Wagenhauser ^ attributes a case of marked tinnitus 
aurium, aggravated by cough and demonstrable objectively 
with the auscultatory tube, to an aneurysmal dilatation of 
the internal carotid ; but as the patient, a girl of nineteen, 
presented besides a marked emphysematous habit, a large 
goiter, and a cyanotic appearance, his explanation is open 
to criticism. Brandeis ^ regarded a noise which was heard 
in a disease of the upper cervical vertebrae as a vascular 
murmur emanating from a dilated vertebral artery. The 
literature contains many cases of aneurysmal dilatation in 
various vascular systems which produced subjective ear 
noises. Among the external vessels of the head the region 
of the temporal, occipital, and posterior auricular arteries 
furnishes examples quoted by Chimani * and Herzog. ^ 
Subjective and objective noises in the head maybe of great 
significance in the diagnosis of aneurysm at the base of 
the brain. In the case of a woman who suddenly began to 
complain of tinnitus aurium and impaired hearing and lost 
consciousness, Varrentrapp ^ found at the autopsy a rup- 
tured aneurysm of the basilar artery. Lebert, '^ in his 
studies on aneurj^sm of the cerebral vessels, calls attention 
to the frequency of tinnitus aurium as a symptom of 
aneurysm of the middle cerebral and basilar arteries ; in the 
case of the latter it may have great diagnostic value as an 
early symptom. Deafness has often been observed in com- 
bination with the subjective noises ; sometimes it comes on 

1 "Arch. f. Augen- u. Ohrenheilk.," vol. TV. 

2 "Arch. f. Ohr.," xix, p. 62. ^ u Zeitschr. f. Ohr.," vol. xi. 
•i " Arch. f. Ohr.," VIII. 

5"]\Ion. f. Ohr.," 1S81, Nos. 8 and 9; with review of cases reported up to 
date. 

6 "Arch. d. Heilkunde," 1865. 

" " Berlin, klin. Wochen.," 1866, pp. 251, 2S2. 



THE EAR, 65 

suddenly, and must be explained partly by the obliteration 
of the arteries supplying the ear, and partly as the result 
of pressure on the auditory nerves. Oppenheim ^ was able 
to auscult a loud pulsating murmur over the left half of the 
skull, which, because of a coexisting ocular disturbance, he 
referred to aneurysm of the posterior communicating artery ; 
but there is no record in the history that the patient had 
been aware of the murmur. Hyrtl ^ contributes the obser- 
vation that the artery of the stapes is sometimes very large, 
and in that case is likely to give rise to vascular murmurs. 

When the character of the entotic vascular niiirmurs is 
examined, it is found that the difference between arterial 
and venous murmurs has been very differently described. 
The arterial murmurs are said to have a distinct pulsating 
character, to be synchronous with the apex-beat, and to 
manifest themselves "as a series of buzzing or pounding 
noises in the ear or in the head" (Kayser^), whereas the 
venous murmurs are breathing or blowing in quality, and 
continuous. As we must depend for a description of the 
murmurs on the statements of the patient, — for even when 
an aneurysmal bruit can be heard objectively we have no 
means of judging whether the patient hears the noise in the 
same way, — it is easily understood why the descriptions 
vary so widely. The patient naturally chooses a com- 
parison from his surroundings or from among the sounds 
he has become familiar with in his calling, so that the 
murmurs have been compared to the rush of water over a 
dam, the rustling of leaves in the forest, the noise of 
machinery and railroad trains, the hiss of boiling water, the 
chirping of a cricket, etc. 

A few examples are given to show that even the general 
character of the arterial and venous murmurs, as just 
described, does not apply in every case. Kayser lays down 
the rule that arterial hyperemia, like the inhalation of amyl- 
nitrite, produces low-pitched, buzzing sounds, while anemia, 
like syncope, gives rise to high, resonant tones. According 
to v. Troltsch, the predominant characteristic of the noises 
in anemia and chlorosis is hissing and blowing. According 
to Stacke, in arteriosclerosis the subjective noises are high in 
pitch ; and it is worthy of remark that although of arterial 

1 "Berlin, klin. Wochen.," 1896, p. 402. 

2 Quoted by Urbantschitsch, " Schwartze's Ilandl).," vol. i, p. 413. 

3 Bresgen's collection 11, part 6, ]i. 2<S. 

5 



66 THE CIRCULATORY SYSTEM. 

origin, the sounds are not intermittent in character. Moos^ 
points out that they are aggravated by anything which tends 
to stimulate the circulation. In his case — mentioned in 
another place — he ascribes the subjective noises to a marked 
dilatation of the sinus of the internal jugular vein. The 
noises which the patient compared to the din of machinery 
and railroad trains were so intense that they drove him 
to commit suicide. The interpretation of this case is 
open to criticism, as there evidently existed a psychosis. 
The noises caused by heart disease and aneurysm are 
usually described as intermittent and buzzing or soughing 
in character. 

The differential diagnosis between entotic vascular mur- 
murs and simple noises in the ear can be established in 
some cases by compressing the corresponding vascular 
trunks — that is, the external and internal carotids, the 
vertebral artery, and the internal jugular vein — which are 
concerned in the blood supply of the ear. The effect pro- 
duced by compressing the blood-vessel will vary according 
as the vascular murmur is arterial or venous in character^ 
and emanates from the distribution of the carotids in the 
tympanum or from the branches of the vertebral artery in 
the internal ear. Schwartze ^ mentions the disappearance 
of pulsating murmurs after compression of the carotid, and 
suggests " ligation of the carotid for the cure of aneurysm " 
to remove the murmurs. In Wagenhauser's case, where 
aneurysm of the internal carotid was suspected, the vascu- 
lar murmur was diminished by pressure on that vessel ; in 
Oppenheimer's case of aneurysm of the posterior commu- 
nicating artery, in which the murmur was heard only 
objectively, compression of the carotid had no effect. 
Von Troltsch ^ quotes Tiirck as saying that pressure on the 
first cervical vertebra alters and usually diminishes the 
murmur momentarily, and, similarly, Dundas Grant^ rec- 
ommends compression of the vertebral artery in cases of 
vascular murmurs, so as to relieve the tension in the distri- 
bution of the basilar arteiy, of which the internal auditory 
is a branch. 

Although the general impression prevails that pressure 

1 " Schwartze's Handb.," vol. I, p. 535. 

2 " Die chir. Krankh. des Ohres," p. 170. 

3 " Lehrb ," 7th edition, p. 606. 

■* Quoted by Brieger, " Klin. Beitr.," p. 139. 



THE EAR. 67 

on the internal jugular vein — as, for instance, by struma 
or a tight collar — produces tinnitus aurium, Boudet^ main- 
tains that the noises can be suppressed by compression of 
the vein. 

On the subject oi embolic disease of the ear in endocarditis 
we have the investigations of Trautmann,^ which confirm the 
extreme rarity of its occurrence and the absence of marked 
symptoms, at least in thrombosis of any of the smaller 
vessels. Embolism of the basilar or of the internal audi- 
tory artery may give rise to sudden deafness, as happened 
in a case of Friedreich's ; ^ but emboli in the smaller arte- 
rial branches of the middle ear do not necessarily cause 
any functional disturbance. 

Trautmann's anatomic investigations on the cadaver con- 
vinced him that embolic processes are more apt to occur in 
the tympanum than in the internal ear, because the arterial 
path from the posterior auricular to the stylomastoid is 
straighter than that which leads from the tortuous verte- 
bral artery to the basilar and internal auditory. It appears 
from Trautmann's observations that of thirteen cases of 
endocarditis four showed petechial hemorrhages in the 
tympanic membrane and the mucous membrane of the 
middle ear ; but his findings can not be utilized for ear dis- 
eases following simple endocarditis without a reservation, as 
most of his patients were cases of ulcerative endocarditis 
and general sepsis, showing septic embolism of cutaneous 
vessels with roseola-like macules and petechial hemorrhages. 
The changes in the ear may be regarded as analogous with 
the latter, and caused, not by endocarditis in general, but 
by the sepsis present in these cases. Habermann^ recently 
reported a case of rather sudden deafness of the right ear, in 
which there was double mitral disease with endocarditis. 

The prognosis of deafness after embolism of the internal 
auditory artery is unfavorable as to recovery of hearing, 
which differentiates this form from that due to hemorrhage 
into the central auditory tract, which usually ends in re- 
covery by absorption. 

1 Quoted by Urbantschitsch from " Henle's Jahresber. ," 1862, p. 520. 

2 " Arch. f. Ohr.," Xiv. p. 73. 

3 Moos, " Wien. med. V^'^ocben.." 1S63, p. 661. 

4 " Verhandl. der D. otol. Gesellsch.," 1898, p. 90. 



III. DISEASES OF THE DIGESTIVE SYSTEM. 



I. DISEASES OF THE DIGESTIVE SYSTEM IN 
THEIR RELATION TO THE UPPER AIR- 
PASSAGES. 

DISEASES AND CHANGES IN FORM OF THE ORAL CAVITY 
IN DISTURBANCES OF NASAL RESPIRATION. 

Morbid changes in the oral mucous membrane and 
changes in the shape of the oral cavity result from obstruc- 
tion of the nasal chambers ; the etiology of the latter and 
its effect on the respiratory passages has already been fully 
discussed. The inspiratory air current, in passing through 
the mouth, exerts a cooling and desiccating influence on 
the mucous membrane, giving rise to a subjective feeling 
of dryness in the mouth and throat, and, from the deposi- 
tion of dust, to a stale, disagreeable taste and general 
anorexia. It seems probable that mouth-breathers are 
more exposed to catarrhal affections of the gums and 
of the mucous membrane covering the tongue and oral 
cavity on account of the greater facility of direct infection^ 
but the supposition has never been proved, any more than 
the statement that they are more disposed to inflammation 
of the tonsils. 

Since Moldenhauer and Bloch, among others, called at- 
tention to the changes produced in the shape of the upper 
maxilla by obstruction of the nasal respiration, the subject 
was carefully investigated by Korner ^ and by his disciple 
Waldon,2 and their statements are confirmed by the obser- 
vations of others. Korner divides the malformations of 
the jaw into those which occur before the period of second 
dentition and those which are produced if there is nasal 
obstruction while that process is going on. 

1 " Untersuchungen iiber Wachsthurnsstorungen und Missgestaltung des 
Oberkiefers und des Nasengeriistes in Folge von Beliinderung der Nasenath- 
mung. " Leipzig, F. C. W. Vogel, 1891. 

2" Arch. f. Lar. u. Rhin.," vol. Ill, p. 233 et seq, 
68 



NASAL RESPIRATION. O9 

The first consists in a "dome-like elevation" of the 
palate, the highest point of which corresponds to the ante- 
rior portion of the roof of the mouth, the posterior surface 
of the median portion of the alveolar process rising almost 
perpendicularly behind the incisors. The curve of the 
alveolar border, which in normal impressions is usually seen 
to correspond to a semicircle, takes the form of an ellipse. 

When the deformity develops during the period of second 
dentition, there is, in addition to these changes, a marked 
upward growth of the superior maxilla in the sagittal axis, 
and a corresponding diminution in the transverse diameter, 
so that the jaw appears both high and narrow. The teeth, 
which had not been affected before, also show the effect of 
the deformity in the position of the central incisors, which, 
owing to the lateral approximation of the alveolar pro- 
cesses and their meeting in an acute angle in the median 
line, are placed with their posterior surfaces facing each 
other. And as, in consequence of the excessive lengthen- 
ing of the jaw, the anterior alveolar border is pushed for- 
ward and loses its perpendicular position, the incisors 
necessarily take the same direction, and usually project 
beyond the lower teeth, reminding one of a rodent. In 
addition to all these changes, there is a general hypoplasia 
of the superior maxilla, which is regarded as a kind of 
arrested development due to the respiratory inactivity of 
the nose. The interior of the nose is also undeveloped, 
and this explains the upward growth of the palate. The 
lateral contraction of the palate is explained, after Korner, 
by "the pressure exerted on the sides of the jaw by the 
stretching of the cheeks when the mouth is open " ; this 
explanation seems plausible, since it is generally accepted 
that the mouth is at rest when closed, and the act of open- 
ing it, which in mouth-breathers becomes habitual, is asso- 
ciated with contraction of the muscles about the jaw. 

Although the lower jaw is equally subjected to the 
lateral pressure of the contracted muscles (which produce 
the approximation and protrusion of the alveolar process 
of the upper jaw), a similar malformation can not result, 
because a counterpressure is maintained from within by the 
tongue, which fixes the rami of the jaw in their normal 
positions. Hence the lower jaw does not, like the upper, 
suffer any alterations when nasal respiration is obstructed. 

The habit of keeping the mouth open results in atrophy 



70 THE DIGESTIVE SYSTEM. 

of the orbicularis oris, which shows itself in the diminished 
width of the lips and shortness of the upper lip, so that the 
lower half of the teeth are not covered. 



DISEASES OF THE DIGESTIVE ORGANS IN RELATION TO 
THE NOSE, THROAT, AND LARYNX, 

Diseases of the teeth play no inconsiderable part in the 
pathology of the antrum of Highmore and of the nose ; 
the ulceration may spread through the alveolar process to 
the mucous membranes of these cavities, a dental cyst 
may simulate an empyema, or a tooth may even develop in 
the antrum of Highmore or in the nose. 

While it must be admitted that diseases of the teeth 
occupy a prominent place in the etiology of suppurative 
processes in the antrum, it would be a great mistake to fall 
under the influence of the dentists, who have claimed the 
pathology of the tributary cavities as their own province, 
and neglect other sources of infection for the nose. It is 
true that many cases of empyema of the antrum are due to 
infection derived from a carious tooth or to the encroach- 
ment of a dental cyst ; but if every suppuration of the 
antrum is to be referred to disease of the teeth, how shall 
we explain the inflammations which occur in the frontal 
sinuses quite as frequently as in any of the other accessory 
cavities ? 

The danger to the antrum of infection from a decaying 
tooth varies with the individual tooth, the anatomic rela- 
tions of the alveolar process, and the size of the accessory 
cavity concerned. 

The lumen of the antrum may be conveniently described 
as representing a pyramid : the base corresponds to the 
lateral wall of the nose, the apex lies in the zygomatic or 
malar process, and the three sides are formed by the inner 
aspects of the facial, orbital, and pterygopalatine or zygo- 
matic surfaces of the superior maxilla. The junction of 
the facial and nasal walls of the cavity comes into close 
relation with the alveolar process, but nearer the median 
line the sockets are separated from the floor of the cavity 
by a thicker ridge of bone. The longer the alveolar proc- 
ess, as roughly determined by the elevation of the roof 
of the mouth, the thicker the mass of bone which separates 
the roots of the teeth from the antrum, and the less 



NOSE, THROAT, AND LARYNX. /I 

prominent their outlines on the inner surface of the cavity. 
These relations are, of course, variable, and the possibility 
of a morbid process spreading from the teeth to the antrum 
depends on whether the roots of the teeth are separated 
from the cavity by a thick layer of bone or only by a 
slender lamella and the epithelial lining of the antrum. 

It may be laid down as a rule, independent of these 
varying anatomic relations, that certain teeth are always 
nearest the cavity, and therefore most dangerous to the 
antrum if they become diseased ; while, on the other hand, 
they also offer the readiest means of access to the antrum 
for therapeutic purposes. The floor of the antrum is 
deepest over the second bicuspid and first molar ; hence, 
whatever the thickness of the intervening bone at other 
points, these two teeth always lie nearest the cavity, and 
constitute the point of election for attacking the maxillary 
sinus through the alveolar process. 

On the subject of periodontal cysts and their extension 
to the antrum of Highmore there is a paper by Kunert^ in 
which he points out the diagnostic points between such a 
cyst and true empyema of the antrum. I am willing to 
admit that protrusion of the facial and orbital plates and of 
the hard palate is characteristic of cysts ; but in bulging of 
the outer wall of the nose, accompanied by a flow of pus 
from the middle meatus, — symptoms referred by Kunert to 
the spontaneous opening of a cyst, — I believe the rhinolo- 
gists will be inclined to exclude any cystic condition from 
the etiology. Kunert betrays his imperfect acquaintance 
with rhinology when in the diagnosis of a true empyema of 
the antrum he utterly ignores the significance of granula- 
tions and polypi in the middle meatus, coupled with dis- 
ease of other adjoining cavities. 

The presence of a tooth in the inferior meatus on the 
floor of the nose or in the antrum admits of two explana- 
tions : either it is an inverted tooth or it is the product of 
a dental papilla which wandered into the nasal cavity before 
closure of the palatal cleft had taken place. Sometimes a 
foreign body lying loose on the floor of the nose, and cov- 
ered or surrounded with swollen mucous membrane, is 
removed from the nose, and, to the surprise of the surgeon, 
turns out to be a fully or only partly developed tooth, 

' " Arch. f. Laryng.," vn, p. 34. 



72 THE DIGESTIVE SYSTEM. 

which must have been there lor years without causing any 
symptoms. 

The theory which formerly prevailed, that spasm of the 
vocal cords in children is due to difficult dentition, has 
been disproved. As will be shown later on, in the section 
on rachitis, the phenomenon must be regarded as a symp- 
tom of the general impairment of nutrition, more particu- 
larly of the rachitic habit. 

The diseases of the palate and of the oral pharynx will 
be found fully treated in the special text-books devoted to 
them, and need not be discussed here. 

Diseases of the esophagus, in the form of tumors, diver- 
ticula, and peri-esophageal abscess, have their effect on the 
upper air-passages whenever the larynx and trachea become 
involved in the morbid process, or whenever the tumor pro- 
duces paralysis by pressure on the laryngeal nerves. Malig- 
nant tumors originating in the highest portion of the esoph- 
agus, at the level of the cricoid cartilage, are prone to spread 
into the interior of the larynx, and it is often difficult to de- 
cide, by the laryngoscopic image, whether the primary seat of 
the tumor is in the larynx or in the esophagus. Whenever 
there are distinct signs of carcinomatous changes in the inte- 
rior of the larynx, and a mass suddenly makes its appearance 
in the pyriform sinus, or, as is sometimes observed, pushes 
its way into the lumen of the larynx over the interarytenoid 
notch, it may be said with certainty that the tumor has in- 
vaded the esophagus. In operating on such cases it must 
be remembered that the process has probably attained such 
dimensions that there is no possibility of a radical cure 
without extensive resection of the esophagus and pharynx. 

The possibility of tumor or dislocation of the esophagus 
producing paralysis of the vocal cords follows logically 
from the course of the recurrent nerves in the groove be- 
tween the trachea and esophagus, which has been suffi- 
ciently described in another place. 

Dyspepsia is often found associated with atrophic fetid 
rhinitis and pharyngitis and with abscess in the cavities 
adjoining the nose, obviously because the pus which enters 
the pharynx is often swallowed. It would be well worth 
while to examine these relations more closely from a 
clinical standpoint, for, as far as my experience goes, this 
cause for chronic gastric catarrh has so far barely received 
a passing mention. When complaints of failing appetite 



NOSE, PHARYNX, AND LARYNX. 73 

and bad digestion are constantly heard in cases of ozena, 
where the cavities of the nose are enormously enlarged 
and its walls covered with crusts, where the pharynx and 
posterior pharyngeal wall is filled with offensive discolored 
masses of secretion, it seems but natural to attempt to 
establish a causal relation between the two conditions. A 
secondary chronic gastritis is readily explained either by 
the anomalies of smell and taste which result from the 
ozena and manifest themselves in paresthesise and anesthe- 
sise, destroying the appetite and causing a bad taste in the 
mouth, or directly by the irritation of the decomposing secre- 
tions in the stomach. 

The American literature ^ contains a few observations on 
the significance of dyspepsia in the etiology of rhino- 
pharyngeal catarrh. Beverley Robinson's remarks on this 
subject are worth quoting : " Dyspepsia," this writer says, 
"increases an already existing pharyngeal catarrh, because 
the eructations of gas act as an irritant, and the acid matters, 
which contain large quantities of butyric acid and similar 
substances, tend to aggravate the condition." 

In regard to spasm of the vocal cords in infants, which is 
said to be caused by defective nutrition of the sensory nerve- 
endings of the vagus in the stomach, there is a discussion 
by Rehn,2 which will be referred to again in connection 
with rachitis. 

The theory that cough may be produced by reflex irrita- 
tion of the pneumogastric in the stomach was formerly 
accepted by physicians, and even now enjoys a wide recog- 
nition among the laity, as we know by the generally ac- 
cepted term " stomach-cough." 

The symptom has now entirely disappeared from the 
literature, for the possibility of such reflex irritation has 
been denied on theoretic grounds (Nothnagel, Naunyn) ; 
nor does the literature furnish any cases which can be 
accepted as proving it absolutely. Even the case reported 
by Bull, 3 in his paper on stomach-cough, which is sup- 
posed to be a clinical observation of stomach-cough of 
reflex origin from irritation of the gastric walls, does not 
convince me, as the paroxysms, which could be brought on 
by pressure on the epigastrium, as well as the entire course 

1 Kef. " Semon's Centralbl," vr, p. 83 ; x, p. 349. 

2 " Berlin, klin. Wochen.," i8g6, No. 33. 

3 " Deutsclies Arch. f. klin. Med.," vol. xu. 



74 THE DIGESTIVE SYSTEM. 

of the disease, with its repeated relapses, appear to me to 
have a distinctly hysteric character. 

When the intestines are in a state of irritation from the 
presence of parasites, reflex tickling sensations and a desire 
to sneeze are often felt in the nose, especially when the irrita- 
tion is in the rectum. These conditions are usually due 
to excessive acidity of the urine, although it is admitted that 
they may be caused by the presence of seat-worms and tape- 
worms. The statement is occasionally met with that spasm 
of the glottis may be due to reflex irritation of worms. 

In cirrhosis of the liver, owing to the impaired nutrition of 
the vessel walls, or as the result of a primary hypertrophy 
of the heart, hemorrhages occur in the mucous membranes, 
sometimes severe enough to constitute epistaxis, but usually 
merely in the form of ecchymoses in the larynx and post- 
nasal cavity. Cases of genuine laryngeal hemorrhage are 
very rare ; Dreyfuss ^ lately published two cases, the 
etiology of which, however, was somewhat obscured by the 
presence of other laryngeal disease. These hemorrhages 
and varicose conditions are easily explained, as are hemor- 
rhages and varicose veins in the esophagus, by the free 
anastomosis existing between the laryngeal veins and the 
tributaries of the inferior and superior thyroid, and, through 
them, with the peri -esophageal veins which belong to the 
portal system. 

The icteric hue manifests itself in the mucous membranes 
by a lemon-yellow color, just as in the epidermis. In 
the larynx it is most marked in the valleculae, above the 
epiglottis, and on the vocal processes. Paresthesiae in the 
throat have been described, exciting cough and hawking, 
A few cases of paralysis of the vocal cords have been 
reported in jaundice with fever. Gerhardt ^ and Hertel ^ 
describe a paralysis of the adductors, with gaping of the 
glottis during phonation, and moderate injection of the vocal 
cords ; the paresis diminished as the jaundice disappeared, 
and phonation was gradually restored. In these cases 
there may have been an intoxication of the nerves, owing 
to their absorbing the cholates. or it may be that paralysis 
occurs only in the infectious form of jaundice, known as 
Weil's disease, for the course of both Gerhardt's and Her- 

, 1 " Miinch. med. Wochen.," 1898, No. 32. 

2 " Die med. Wochen.," 1887, p. 325. 

3 « Chaiite Ann.," 1891, xvi. 



NOSE, PHARYNX, AND LARYNX. 75 

tel's cases strongly suggest that disease. M. Schmidt ^ calls 
attention to the paroxysmal cough sometimes excited by 
the reflex irritation of gall-stones, and mentions Cahn's 
case of vasomotor coryza (hydrorrhea nasalis) directly 
caused by hepatic colic, and another in which there Avas a 
causal relation between vasomotor coryza and round ulcer 
of the stomach. 

Finally, cholera asiatica and severe cases of ordinary 
cholera may give rise to various disturbances in the upper 
air-passages. The most familiar of these is the aphonia, 
or vox cholerica, which accompanies the attack of cholera ; it 
is usually attributed to weakness of the muscular tissues 
which are deprived of the necessary moisture. Matter- 
stock 2 made a series of laryngoscopic examinations in the 
Wiirzburger Klinik during a cholera epidemic. It appears 
from his investigations that the interior of the larynx be- 
comes cyanotic, and the vocal cords discolored and moder- 
ately injected. The most conspicuous change was a marked 
prominence of the vocal processes, the vocal cords being 
very much hollowed out, so as to present the shape of a 
sickle. Wide gaping of the glottis during phonation 
accounted for the aphonia, which was not constantly pres- 
ent, the patient regaining his voice temporarily under the 
influence of excitement or after the application of the faradic 
current. Matterstock rejects the foregoing interpretation, 
which is the one generally accepted, and refers the paresis 
to nervous influences ; the aphonia, according to him, is 
not dependent on the excessive loss of fluid, so that one 
might regard the vox cholerica as a toxic paralysis, analo- 
gous to those which occur in the course of other infectious 
diseases. 

The croupous and diphtheric inflammations of the 
pharyngeal and laryngeal mucous membranes in cholera 
are interpreted by Liebermeister ^ as superficial necroses, 
due to the profound disturbance of nutrition and circulation, 
comparable to similar complications in typhoid fever, 
variola, and puerperal fever. 

1 " Die Kranlvh. der ob. Luftwege," 2d ed., p. 749. 

2 " Berl. klin. Wochen.," 1874. 

3 " Die Cholera," in Nothnagel's " Spec. Path. u. Therap.," vol. iv, i, 
p. 68. 



76 THE DIGESTIVE SYSTEM. 



2. DIGESTIVE SYSTEM AND DISEASES OF THE 
EAR. 

The influence of disease of the intestinal canal on the ear 
is inconsiderable. Moos and Haug refer to auditory dis- 
turbances said to have been observed by Meniere ^ in gas- 
tric disease, and Haug mentions one or two other unim- 
portant cases, but both devote a great deal of attention 
to diseases of the teeth as the cause of aural disturbances. 

Of all the complications presently to be mentioned there 
is only one — neuralgia localized in the ear after caries of 
the teeth — that appears to me to be definitely proved. As 
for the exudative otitis media in diseases of the teeth, which 
is said to result from reflex irritation of the dental branches 
of the trigeminus, — which, as will be explained in another 
place, exercises a trophic influence on the mucous mem- 
brane of the middle ear, — I do not consider that the etio- 
logic relationship has been clearly established. 

It happens every day that a patient comes to the doctor 
complaining of earache, and the cause of this alleged " ear- 
ache " is found in a carious tooth ; or a patient with acute 
otitis media describes the pain as radiating to the molars. 
It is, no doubt, this radiation of the pain in earache that is 
responsible for the popular belief that toothache can be 
relieved by dropping warm oil into the external auditory 
meatus, and induces many women of the lower classes to put 
cotton in their ears for the same purpose. It is not at all 
surprising that the people at large should harbor the super- 
stition that a running ear may be caused by the process of 
first or second dentition, when we remember the layman's 
talent for confusing cause and effect and his remarkable in- 
genuity in interpreting reflex conditions, before which the 
inventiveness of the most ingenious discoverer of reflex 
neuroses sinks into insignificance ; but that such views 
should still prevail in medical circles ^ is simply incompre- 
hensible. It is indeed difficult to conceive how a purulent 
otitis media could be the result of the physiologic process 
of dentition, except on the very improbable hypothesis 
that the inflammatory irritation of the gums was communi- 

1 " Rev. mens, de lar.," etc., 1886, No. 6. 

2 For instance, quoted by Moos : Burnett, " Am. Journ. of Otol.," vol. 11, 
part IV, p. 285. 



THE EAR. 'J'J 

cated to the middle ear by way of the postnasal space and 
the Eustachian tube. For similar reasons I am inclined 
to deny any connection between purulent otitis media and 
caries of the teeth, and the cases published in support of 
the theory do not appear to me to bear the scrutiny of 
closer inspection. Thus, a woman has a tooth filled, and 
during the following night is taken with vertigo and head- 
ache, her hearing is impaired, and she has tinnitus aurium. 
A week later, suffering with acute middle-ear catarrh in 
process of regeneration, she comes under the care of an 
ear specialist, who concludes that the aural inflammation is 
the result of filling the carious tooth. But it is much more 
likely that the patient originally referred the pain of an 
acute otitis to a tooth, and as she happened to have a 
carious tooth at the time, she had it filled, without, of 
course, arresting the course of the inflammation ; when, a 
week later, the otologist found only the remains of an 
otitis, he hastily concluded, without going into the case 
very critically, that the carious tooth was the primary cause. 
A similar case was observed by Blau ; ^ he, however, was 
too critical to admit an etiologic connection between the 
dental and the aural conditions without a reservation. 
Haug,2 on the other hand, attributes a case of hemorrhagic 
exudation into the tympanic cavity, with ecchymoses in 
the external auditory meatus, to pulpitis of a molar tooth. 
The spontaneous cure of the aural affection within sixteen 
days after the tooth was extracted does not confirm the 
diagnosis, as any uncomplicated acute hemorrhagic in- 
flammation would have subsided just as rapidly. Nor is 
there any better proof in a case described by Schwartze^ as 
" acute purulent otitis media with caries of the mastoid 
process resulting from caries of a second molar." 

The ingestion of food may be seriously interfered with if 
the ear disease involves the articulation of the lower jaw, 
and mastication, or even opening the mouth, becomes pain- 
ful or impossible. Such disturbances occur most com- 
monly in otitis externa, with furuncle on the anterior wall 
of the meatus, and infiltration of the parts about the joint. 
Extensive caries of the temporal bone and malignant tumors 

1 " Arch. f. Ohr.," x.xni, p. 12. 

2 " Verh^ndl. der D. otol. Gesellsch.," 1S95, p. 41. 

3 " Zeitschr. f. Ohr.," xxili. 



78 THE DIGESTIVE SYSTEM, 

in the external or middle ear may destroy some of the 
tissues entering into the construction of the joint. 

Disturbances of the sense of taste due to ear disease 
will be discussed in the section devoted to nervous dis- 
eases. 

In persons afflicted with chronic purulent otitis media 
the trickling of pus through the Eustachian tubes intO'the 
pharynx (according to Itard ^) sometimes produces nausea 
and vomiting, with bad taste in the mouth and indigestion. 
But it is chiefly during infancy and early childhood that the 
connection between diseases of the gastro-intestinal canal 
and inflammations and suppurations in the middle ear is 
noticeable. The striking coincidence of digestive disturb- 
ances and running of the ear, and the frequent presence 
of pus and inflammatory exudate in the ears of children 
who have died of enteritis, leave no room for doubt that 
we have to deal with a deeper etiologic relationship and 
not merely with an accidental coincidence. 

It has taken a long time to arrive at a clear understand- 
ing of the nature of this connection ; up to a very recent 
date the most extrav^agant suppositions were entertained 
regarding the normal condition of the middle ear in the 
new-born and during the first months of the infant's life, 
and, in consequence, widely divergent interpretations were 
suggested for cases in which the autopsy revealed the 
presence of a mucopurulent secretion, with swelling and 
injection of the mucous membrane of the middle ear. 
The process of involution which takes place in the middle 
ear of the new-born, consisting in resorption of the so- 
called fetal pad of mucous membrane or mucoid embry- 
onic connective tissue which fills the cavities of the middle 
ear during intra-uterine life, led certain authors to explain 
the presence of mucopus in the middle ear of infantile 
cadavers as a physiologic formation due to a persistence 
of the embryonic tissue.^ This confusion of ideas con- 
tinued until Hartmann ^ instituted his first systematic 
investigations on the cadavers of infants. The confusion 
was aggravated by the current belief that the diagnosis of 
diseases of the ear and the interpretation of the otoscopic 
image in infants were based on an entirely different set of 

^ Quoted by Urbantschitsch, " Lehrb.," 2d ed.. p. 251. 

2 For the literature see AschofF, " Zeitschr. f. Ohr.," xxxi, p. 345. 

* " Deutsche med. Wochen.," 1894, No. 26. 



THE EAR. 79 

principles, and offered peculiar difficulties, as compared 
with similar conditions in adults. 

Hartmann repeatedly pointed out the significance of puru- 
lent otitis media in the nutritive disturbances of infants ; 
then Ponfick ^ contributed his evidence to the elucidation of 
the subject, and Goeppert ^ showed that purulent otitis 
media is often a sequel of intestinal diseases in infants, 
which up to that time had been practically disregarded. 
We have already seen that the interdependence of lung and 
ear diseases has been known and studied for some time, and 
now Goeppert finds that the percentage of ear complica- 
tions is much higher among children suffering from intes- 
tinal troubles than it is among those admitted for other 
diseases; 12^ of the former and 39^ of the latter class 
were found to have healthy ears. As to the mode of 
origin of ear diseases in gastro-intestinal affections, it is just 
as difficult to explain as it is to decide in cases of long 
standing whether the ear or the intestinal tract is the 
primary seat of disease. The question may, perhaps, best 
be answered by referring to what has been said in connec- 
tion with purulent otitis occurring in the course of lung 
diseases : the power of the organism to resist infection 
having been weakened by disease, the infant is more prone 
to suppurative processes in the tympanic cavity ; and in the 
same way marasmus must be regarded as a frequent cause of 
disease in the ear. Goeppert's theory, that infection during 
an intestinal disease occurs solely through the entrance of 
vomited matter into the middle ear by way of the tubes, can 
hardly be accepted in all cases. 

Secondary nutritive disturbances play an important role 
in primary ear diseases in the case of infants. A regular 
digestion and a uniform increase in the body-weight afford 
the best criterion of an infant's health, for its digestive 
organs are so sensitive that the slightest local or general 
disturbance may suffice to upset its stomach. If there is a 
purulent focus anywhere in the body, auto-intoxication will 
be much more likely to result from the absorption of the 
products of metabolism in the infant than in the adult, and 
will show itself chiefly in the organs which are functionally 
the most important : that is, it will be followed by indiges- 
tion and a falling-off in weight. Thus, there is danger of 

1 Ponfick, << Berlin, klin. Wochen.," 1897, No. 38. 
^ Goeppert, "Jahrb. f. Kinderheilk.," vol. XLV, p. I. 



80 THE DIGESTIVE SYSTEM. 

auto-infection whenever the secretions are retained in the 
middle ear in purulent otitis media, because there is no per- 
foration, or only an insufficient one, in the tympanic mem- 
brane ; for the toxins contained in the pus are distributed 
throughout the body, and set up an enteritis, with its train 
of evil consequences. Hartmann ^ investigated these con- 
ditions in the Berliner Kinderklinik, and found, as Ponfick 
had, that purulent otitis media and intestinal catarrh react 
on each other so directly that paracentesis and evacua- 
tion of the secretions "may be followed by return of 
the disturbed digestive function to the normal, and an 
increase in weight instead of a loss." In one case of 
acute otitis media, when a second rise in temperature 
clearly indicated paracentesis, the intestinal condition pre- 
sented a perfect reflection of the state of the suppurative 
process. On two other occasions retention of the pus 
was followed by indigestion and a loss of weight, but both 
conditions immediately began to improve after paracentesis 
had been performed. Auto-infection may also result, as Pon- 
fick has shown, from swallowing the pus that has reached 
the pharynx through the Eustachian tubes. 

Hartmann rightly concludes from his observations that in 
all intestinal diseases of infants accompanied by rise in tem- 
perature and loss of weight the ears should be examined 
to ascertain whether any inflammation is present. 

Brieger ^ mentions the rare occurrence of icterus in the 
course of a genuine otitis media, and explains it by the 
decomposition of blood-corpuscles in hemorrhagic exuda- 
tions in the tympanic cavity. A slight icteric discoloration 
of the skin, which may be explained in a similar way, is 
rarely seen a few days after an operation on the mastoid 
process. 

1 " Verhandl. der D. otol. Gesellsch.," 1898, p. 87. 
- " Klin. Beitr. zur Ohrenheilk.," p. 64. 



IV. DISEASES OF THE BLOOD. 



U ANEMIA. 

The three forms of anemia — simple or symptomatic ane- 
mia, chlorosis, and pernicious anemia — will be discussed 
together, as the symptoms they produce in the organs 
under discussion are essentially the same. 

A constant symptom noted by inspection of the upper 
air-passages is a marked pallor of the mucous membranes, 
which may be very intense even in the nose, where anemia 
does not, as a rule, produce any noticeable alteration. In 
acute anemia after hemorrhage, and in the anemia of star- 
vation, olfactory hallucinations and exaggerated sensitive- 
ness of the olfactory nerves ^ are observed. These are prob- 
ably analogous to the rarely mentioned auditory hallucina- 
tions,^ and, though we are unable to explain them, cerebral 
anemia is no doubt the cause. 

The mucous membrane of the pharynx and larynx, espe- 
cially in chlorotic subjects, is often the seat of hyperesthesia 
and paresthesiae, such as dryness and tickling in the throat, 
exciting cough and hawking. Chlorotic young girls often 
complain that the voice is weak, is easily tired by talking 
and even more by singing, and that it becomes hoarse. 

The laryngoscopic image often shows nothing but a slight 
insufficiency of the vocal muscles and of several adductors. 
It seems probable that this functional aphonia is merely the 
expression of a weakened state of the muscles due to the 
anemia, for laryngoscopic examination often shows that the 
cords move perfectly with the first efforts at phonation ; 
paresis developing only after a number of movements have 
been made, as the muscles become fatigued very rapidly. 

Among aural symptoms in anemic states are tinnitus and 
vertigo, and, more rarely, difficult hearing, which may go^ 
on to total deafness. Opinions are divided on the question: 

^ Hoffmann, " Lehrb. der Constitutionskrankh. ," pp. 19 nnd 36. 
2 Haug, " Krankh. des Ohres," p. 176. 
6 81 



82 THE BLOOD. 

of the seat of these disturbances. The results of a func- 
tional examination point to disease of the internal ear, but 
no characteristic signs are elicited. The anemic distur- 
bances of the hearing have been attributed to anemia of the 
labyrinth, which is assumed to give rise to the symptoms 
of tinnitus, difficult hearing, and vertigo ; but no satisfactory 
explanation has been offered of the way in which anemia of 
the labyrinth could produce such phenomena. 

As most cases of grave anemia are, in fact, associated 
with tinnitus and vertigo, it is quite natural to regard these 
symptoms as the expression of an anemia of the labyrinth, 
which has brought on a pathologic condition of irritation in 
the end-organs of the auditory nerve in the labyrinth. 
This view of the origin of tinnitus and vertigo finds some 
support in a case reported by Lermoyez.^ in which the tin- 
nitus disappeared and hearing improved after food was 
taken, but the symptoms reappeared in a few hours, with 
returning inanition. Impaired hearing from anemia may 
perhaps be interpreted as the expression of a nutritive dis- 
turbance in the organ of Corti, which would explain such 
cases as Abercrombie's, in which the patient was deaf in the 
sitting posture, but regained his hearing perfectly on lying 
down ; but there is another possible explanation for this 
case as well as for Litten's,^ — where a chlorotic subject suf- 
fered with deafness lasting several hours, sometimes, but not 
always, after a fainting fit, — namely, that the deafness is 
due to anemia of the deep nucleus of the auditory nerve in 
general anemia of the brain. These periodic attacks of 
deafness — which may occur without any permanent lesions 
of the auditory apparatus, as shown by the fact that the 
deafness is variable and eventually ends in recovery — are in 
marked contrast to deafness coming on suddenly after a 
severe hemorrhage, in which the prognosis is very unfavor- 
able. Such sudden deafness after profuse bleeding at the 
nose was observed by Urbantschitsch^ ; it also occurs in 
greater or less degree after difficult labors attended with 
great loss of blood. It can not be explained as a result of 
the sudden change in blood pressure, and must be attributed 
to a more profound lesion. Some light has been thrown on 
its mode of origin by the discovery of hemorrhages in the 

1 " Ann. des mal. de I'oreille," 1896, part II, p. 28. 

2 " Bleichsucbt," Nothnagel's " Spec. Path. u. Ther.," p. 97. 

3 "Arch. f. Ohr.," xvi, p. 105. 



ANEMIA. LEUKEMIA. 83 

labyrinth by Habermann^ in a series of autopsies on sub- 
jects who had died of simple and pernicious anemia. These 
hemorrhages appear to be analogous to those found in 
anemia in the spinal marrow, in the medulla, and in the 
nerve-trunks. 

The theory which seeks to explain that tinnitus aurium 
in anemia and chlorosis is the noise of the blood stream 
perceived by the patient himself lacks confirmation, and does 
not seem probable, as tinnitus aurium is not a constant feat- 
ure in chlorosis with vascular murmurs. The condition 
Avhich obtains when the vessels are diseased has been ex- 
plained elsewhere, and we will only mention here that the 
variation in the perception of subjective noises in chlorosis 
has been attributed by Wolf to differences in the conduct- 
ing power of the bone, depending possibly on imperfect 
development of the mastoid cells. 

Lermoyez suggests the inhalation of amyl nitrite as a 
diagnostic aid in determining whether tinnitus and vertigo, 
in a given case, are due to anemia, as its administration is 
followed by hyperemia and consequent disappearance of 
the symptoms. 



2. LEUKEMIA. 

ALTERATIONS IN THE UPPER AIR-PASSAGES IN 
LEUKEMIA. 

Associated with the waxen hue of all the mucous mem- 
branes in leukemia there is a peculiar yellowish pallor of 
the upper air-passages, more conspicuous in the pharyngeal 
cavity and in the larynx than in the nose, where changes 
of color are not so marked. As an expression of 
the hemorrhagic diathesis in leukemia we frequently have 
epistaxis, which may occur at any stage of the disease 
without appreciable macroscopic alterations in the nasal 
mucous membrane, but appears to be most common in the 
acute form of leukemia, which has lately become better 
known through the investigations of Ebstein. Microscop- 
ically, Suchanneck ^ found lymphoid infiltrations in some of 
the arterioles of the nasal mucous membrane, and large 
accumulations of pigment around the vessels. Similar 

^ " Prag. med. Wochen. ," 1890, No. 39. 
2 " Zeitschr. f. Ohr.," xx, p. 42. 



04 THE BLOOD. 

hemorrhages are found in the external skin and in the 
mucous membranes, as well as in the pharynx and 
larynx. 

But in addition to these minor changes, during leukemia 
we find in the pharynx and larynx lymphoid nodules, 
lymphomatous infiltrations of the mucous membranes with 
secondary necrosis, and ulceration, making up a clinical 
picture of genuine leukemic pharyngitis and laryngitis. 
Virchow's ^ description of the condition has become classic, 
and well deserves quoting : " Lymphoid nodules appear on 
the inner surface of the epiglottis, on the aryepiglottic folds, 
and over the entire surface of the larynx and trachea, 
sometimes even in the bronchi, presenting usually a small, 
whitish, moderately raised and rounded swelling of rather 
soft consistency, frequently situated at the orifices of gland 
ducts, but also found in other situations." The nodules 
are usually discrete, but occasionally they coalesce and 
form a dense uniform infiltration, as observed by Vlrchow 
in the upper segment of the larynx. Sometimes they 
attain to a large size and form tumors. Such tumors, 
having the consistency of marrow and a glossy surface, are 
found on the mucous membrane of the pharynx, at the 
base of the tongue, and on the tonsils. ^ Thus, hyper- 
trophy of the palatal and pharyngeal tonsils is often a valu- 
able sign of leukemic pharyngitis. Virchow remarks that 
the nodules show no tendency to undergo fatty or cheesy 
degeneration, and thereby distinguish themselves from mili- 
ary tubercles, which they resemble in external appearance. 
We also have superficial ulcerations (as in the intestine), 
which, although they also more rarely affect the epiglottis, ^ 
and have been observ^ed in one instance on the vocal cords 
in the form of flat ulcers with thickened and slightly red- 
dened edges, ■* show a predilection for the fauces and folli- 
cles of the tongue. In some cases the tonsils and fauces 
take on a dark red, livid color, become greatly swollen, 
and then undergo necrotic disintegration. This is often 
associated with a gangrenous form of stomatitis and gin- 
givitis, which strongly suggests grave mercurial intoxi- 

1 " Krankh. Geschwulste," vol. n, pp. 569 and 574. 

2 Recklinghausen, " Virch. Arch.," vol. xxx, p. 370. Mosler, " Virch. 
Arch.," vol. XLII, p. 445. 

* Frankel, " Deutsche med. Wochen.," 1895, p. 679. Kraus, Nothnagers 
" Spec. Path. u. Ther. ," xvi, I. Th., I. Abth., p. 291. 

* V. Recklinghausen, " Virch. Arch.," xxx, p. 370. 



LEUKEMIA. 85 

cation or scurvy (Kraus). ^ It is of comparatively frequent 
occurrence in acute leukemia, and is probably due to bac- 
terial infection of the mucous membrane which has been 
deprived of its superficial epithelium by some mechanical 
trauma and, owing to its impaired nutrition, is unable to 
offer any resistance to the invasion of pathogenic germs. 

Lori 2 and Hoffmann ^ have reported paralyses of the 
recurrent nerve from pressure or traction of the leukemic 
tumors on the vagus or recurrent. 

The same alterations are found in pseudoleiikeinia as in 
leukemia, but the literature on the subject is very scanty. 
Stieda * and Kiimmel ^ observed diffuse infiltrations, which 
in the former's case led to a stenosis requiring tracheotomy 
for its relief, and in the latter's presented a peculiar mar- 
row-like appearance and caused a thickening of the entire 
mucous membrane, as well as of the aryepiglottic folds and 
the posterior arc of the entrance to the larynx, and led 
to a laryngeal stenosis. In a case reported by Kraus ^ the 
mucous and muscular tissues of the pharyngeal vault and 
posterior nares were replaced by a hard, whitish mass, 
slightly raised above the level of the surrounding parts. 
Necrotic disintegration of the tonsils has occurred in pseudo- 
leukemia, and hemorrhages from the nose, pharynx, and 
larynx are sometimes observed. 

Contrasted with these diffuse pseudoleukemic infiltrations 
we meet with circumscribed lymphatic tumors on the 
epiglottis and on the base of the tongue, as observed by 
Beale '^ and Eppinger ^ in general lymphomatosis. 

With symptoms such as these, which in Eppinger's case 
led to a clinical diagnosis of multiple carcinomatosis, one 
may well hesitate whether to ascribe the neoplasms to 
pseudoleukemia or to consider them as idiopathic malignant 
tumors. 

There is another form of morbid growth, known as 
lymphosarcoma, to which it is even more difficult to assign 
a place among the pseudoleukemias. According to Kun- 

1 Kraus, Nothnagel's " Spec. Path. u. Ther.," xvi, i.Tb., i. Abtli., p. 291. 

2 " Die Veranderungen des Rachens," etc., p. 94. 
2 " Lehrb. der Constilutionskiankh." 

■* " Arch. f. Laryng.," IV, p. 46. 

* "Verhandl. der D. otol. Gesellsch.," 1896. 

* Loc. cil. , p. 303. 

" Quoted from Stieda, " Arcli. f. Laryng. ," vol. iv. 

8 In Klebs' " Ilandb. der path. Anat.," 7th ed., 1S80, p. 209. 



86 THE BLOOD. 

drat,i "lymphosarcoma is more closely allied to lymph- 
oma, especially of the pseudoleukemic variety, than it is 
to sarcoma, although it differs from the former by its 
atypical structure, its mode of growth, and its tendency 
to invade neighboring tissues." The close relation exist- 
ing between pseudoleukemia and lymphosarcoma is shown 
by the tendency of pseudoleukemic lymphomata to change 
into lymphosarcomata. Kundrat describes them as origi- 
nating in lymph glands (which consist of follicular and 
adenoid tissue) in certain regions, following the course of 
the lymph-channels in their subsequent growth. Lympho- 
sarcomata often originate in the structures of the pharynx ; 
and, according to Stork, ^ the disease frequently begins 
as a hyperplasia of the pharyngeal tonsil, simulating the 
picture of adenoid vegetations. The general appearance 
of the patients, their pallor and cachexia, and the enlarge- 
ment of the lymphatic elements in the mesentery and 
retroperitoneal space and of the lymphatic glands generally, 
which is found at the autopsy, point to leukemia, although 
the differential diagnosis is indicated by the absence of 
hepatic and splenic alterations. The tonsils and the folli- 
cles of the tongue and of the posterior pharyngeal wall 
may become enlarged, or an extensive infiltration distributes 
itself over the posterior and lateral walls of the pharynx, 
and appears in the larynx either primarily or as an exten- 
sion from the pharynx. The infiltrated areas usually 
become the seat of tumors, which differ from similar 
growths in leukemia in their tendency to cicatrization. In 
the literature there is no record of hemorrhasres. 



THE MANIFESTATIONS OF LEUKEMIA IN THE EAR. 

It has been known for some time that the ear sometimes 
becomes diseased in the course of leukemia. Vidal and 
Isambert found auditory disturbances in three out of 
thirteen and in four out of forty-one cases, respectively, but 
in the absence of reliable clinical observations and anatomic 
studies the nature of the aural disease and its connection 
with leukemia remained shrouded in mystery. In 1884 
Politzer published a paper on the subject, and since then a 

1 " Wien. klin. Wochen.," 1893, Nos. 12 and 13. 

2 Nothnagel's " Spec. Path. u. Ther.," Xiil, 2. Th., I. Abth.; vol. I, p. 204. 



LEUKEMIA. ^"J 

few Other cases were reported. Finally, Schwabach ^ con- 
tributed a decided addition to our knowledge of leukemic 
disease of the ear by five observations of his own, with 
anatomic notes, and thereby brought the total number of 
cases reported up to fifteen. 

It has been mentioned that, according to Vidal and Isam- 
bert, the proportion of aural complications in leukemia is 
lofo ', Schwabach puts it at ZZ%, as his five cases of ear 
disease represent the proportion among fourteen cases 
of leukemia. F. A. Hoffmann ^ also considers disturb- 
ances of the hearing fairly common in leukemia. 

The aural disease may appear at any time in the course 
of the general disease, but is most frequent in chronic 
cases during the last few weeks before death. 

The auditory disturbance is usually profound and points 
to disease of the internal ear ; as a rule, the onset is sudden, 
with vertigo, tinnitus aurium, and sometimes vomiting, and 
is immediately, or within a few days or hours, followed by 
marked reduction in the hearing or even by total deafness. 
In many cases, including the five out of the fifteen reported 
by Schwabach, the aural phenomena made their appearance 
suddenly, simulating the picture of Meniere's symptom- 
complex. 

It has not as yet been determined just how far one is 
justified in assuming a causal relation between leukemia and 
these attacks of deafness which do not present any definite 
clinical type. The assumption that there is a true leukemic 
form of ear disease is amply justified by the investigations 
of Schwabach, who found in fourteen of the fifteen cases 
examined so far anatomic alterations which were undoubt- 
edly dependent on the leukemia. 

These changes, which were also observed by F. A. 
Hoffmann, consist in hemorrhages and in lymphomata 
situated not only in the labyriiith, but also in the auditory 
nerve and its branches. Aggregations of leukocytes or lym- 
phatic infiltrations with extravasations of blood were fre- 
quently found in the trunk of the auditory nerve, ^ in the 
cochlea and vestibule, and in the semicircular canals ; some- 
times pigmentation was present — a consequence of former 
hemorrhages. The marrow-spaces in the spongy tissue of 

1 " Zeitschr. f. Ohr.," xxxi, p. 103. 

2 " Lehrb. der Constitutionskrankh.," p. 79. 

3 Alt und Pineles, " Wien. klin. Wochen.," 1896, No. 38. 



iSb THE BLOOD. 

the mastoid process may be filled to bursting with mono- 
nuclear leukocytes, interspersed with hemorrhagic extrava- 
sations. It would appear that these masses sometimes or- 
ganize and are converted into connective or bony tissue. 

A unique case is reported by Kast ^ : The labyrinth and 
auditory nerve were intact, but in the medulla there was an 
area corresponding to the olivar)^ nucleus, and to the 
nuclei of the hypoglossus, glossophar^aigeal. vagus, audi- 
tory, and facial nerves, in which the medullated nerve- 
fibers were diminished. Yet here bulbar phenomena had 
not been observed, for the only clinical symptoms were im- 
paired hearing and facial paralysis. Facial paralysis was 
also present in one of Schwabach's cases. 

The complications of the middle ear are less pronounced 
and less frequent, and the external meatus and tympanic 
membrane scarcely ever present alterations referable to 
leukemia. If we disregard the deviations from the normal 
observed in the otoscopic image, — calcifications or opacities 
w^hich had nothing to do with the leukemic process, — we 
find few instances of hemorrhage or injection of the mem- 
brane and external auditory meatus. Occasional extrava- 
sations of blood, with a variable admixture of red and 
white blood-corpuscles, have been observed ; more fre- 
quently the mucous membrane of the middle ear was 
thickened, but it w^as rarely the same extensive leukemic 
infiltration as that which occurs in the internal ear. 

These findings are sufficiently characteristic to remove 
any doubt that ear disease of leukemic origin is possible. 
But there is no reason for adopting the opinion of Gra- 
denigo,^ based on three cases, that an inflammatory pro- 
cess in the ear must be regarded as an essential predispos- 
ing factor of ear complications in leukemia. 

Examination with the tuning-fork is of the greatest im- 
portance in the diagnosis of leukemic ear disease ; there 
are, it is true, a few cases where the hearing was only 
slightly impaired, even for whispered sounds, but they are 
very exceptional compared to those which are character- 
ized by great reduction in the hearing or even total deaf- 
ness. Without the results of the functional test, which 
incidentally enables us to determine whether the sound- 
conducting or the sound-perceiving apparatus is chiefly 

1 " Zeitschr. f. klin. Med.," 1895. 

2 " Arch. f. Ohr.," xxni, p. 261. 



LEUKEMIA. 89 

affected, the symptoms of tinnitus and vertigo are of no 
value in the diagnosis of leukemic disease of the organ 
of hearing, as both phenomena may be present in this 
as in other morbid states of the blood-producing organs, 
especially in anemia, quite independent of any organic lesion 
in the ear. 

The prognosis is unfavorable, though there may be tem- 
porary improvement in the hearing. 

Our knowledge of auditory disturbances in pseudoleu- 
kemia is very limited. Kiimmel^ reports a case which he 
observed very carefully, and in which the tympanic mem- 
brane was dark blue, almost violet in color, the handle of 
the malleolus being very distinctly seen. At the autopsy 
an extravasation of blood, mixed with leukocytes, was found 
in the middle ear. In a case of Hodgkin's disease reported 
by Brauneck^ it is said that the hearing, which had always 
been bad, became worse toward the end, and the diagnosis 
of disease of the labyrinth or of the central organs was 
made by an ear specialist. 



3. HEMORRHAGIC DIATHESES, 

In the hemorrhagic diatheses — hemophilia, purpura, and 
scorbutus — the same processes are found in the mucous 
membranes as in the skin. Ecchymoses and hemorrhages 
may appear in the mucous membranes of the upper air- 
passages, just as they attack the external auditory meatus, 
the tympanic membrane, and the middle ear. 

These complications are, however, rarely observed, and 
their diagnosis, when they appear in connection with the 
primary disease, presents no difficulties, so that nothing 
would be gained by giving a detailed description, and I 
shall content myself with presenting a few examples of the 
individual varieties, culled from the literature. 

Epistaxis occupies the first place among spontaneous 
hemorrhages from mucous membranes in hemophilia ; 
among 236 hemorrhages of various kinds 122, according 
to one authority, 3 were from the nose. In the same place 

1 " Verliandl. der D. otol. Gesellsch.," 1896. 

2 " Deutsches Arch. f. klin. Med.," vol. XLIV, p. 297. 

3 Quoted from Hoffmann, " Lehrb. der Constitutionskrankh.," p. 121, 
No. 43. 



90 THE BLOOD. 

a quotation is found from Eichhorst, to the effect that the 
hemorrhage may be preceded by perversions of the senses 
of taste and smell ; one patient could smell, another taste, 
the approach of his hemorrhage. 

I have seen hemorrhages from the larynx in a bleeder, 
a young woman of twenty-five, in association with periodic 
subcutaneous and other hemorrhages. The patient ex- 
pectorated blood, and in the laryngoscopic image the blood 
could be seen trickling from a point at the posterior ex- 
tremity of the left false vocal cord and spreading over the 
adjacent parts, while the entire mucous membrane, includ- 
ing the true vocal cords, showed marked redness. The 
attacks usually lasted from one to two days, and during 
the intervals of freedom from hemorrhage the laryngeal 
image was entirely normal and the source of the hemor- 
rhage could not be recognized. 

An excellent example of hemophilic alterations in the 
ear is furnished by a case of Rohrer's.^ in which there were 
hemorrhages in both tympanic membranes, which were 
dark red in their entire extent. A week later there was 
another hemorrhage in both membranes, which were deeply 
injected ; on the left side the membrane was dark red, 
almost black, in color, with the handle of the malleolus 
sharply defined in white against the dark background — a 
sign that there was a hemorrhage in the middle ear. Haug ^ 
reports one case of hemorrhage lasting several hours from 
rupture of the ear-drum by a blow, and another in which 
minute punctiform ecchymoses appeared in both mem- 
branes after an attack of sneezing. These alterations may, 
however, occur in anybody, whether he be a bleeder or not, 
and are not in any sense to be considered characteristic of 
hemophilia. 

In purpura haemorrhagica the occurrence of epistaxis,^ 
ecchymoses, and subcutaneous hemorrhages in the larynx, 
as well as of ulcerations in the pharynx and larynx, has 
been reported. Krieg * gives a reproduction of hemor- 
rhage on the laryngeal surface of the epiglottis in purpura ; 
Schnitzler,'^ a picture of diffuse hemorrhages from the true 
and false vocal cords in morbus maculosus Werlhofii. 



Reported in "Arch. f. Ohr.," xxxii, p. 59. 

" Die Krankh. des Ohres," p. 179. 

E. Wagner. " Deutsches Arch. f. klin. Med.," xxxix, p. 475. 

" Atlas," PI. in, Fig. 7. 5 « Atlas," PI. n. 



HEMORRHAGIC DIATHESES. 9 1 

Musser ^ mentions inflammation of the throat simulating 
diphtheria in purpura. Kaposi ^ saw an ulcer on the epi- 
glottis. E. Wagner ^ described extensive ulcerations in the 
larynx and pharynx ; and the laryngoscopic examination 
showed marked turgescence and intense redness of the epi- 
glottis and aryepiglottic folds, and at the autopsy there were 
found ulcers varying in size from a split pea to a dime, 
some with a granulating and others with a smooth base, 
situated on the vocal cords, the aryepiglottic fold, near the 
free border of the epiglottis, and on the posterior and lateral 
walls of the pharynx and velum palati. Wagner regards 
these ulcers as the expression of a process analogous to a 
cutaneous erythema. 

Moos 4 and Haug ^ are the only ones who have de- 
scribed alterations in the ear. The former found a hema- 
totympanum with ecchymoses in the bulging tympanic 
membrane ; the latter, petechise in the cochlea and ex- 
ternal auditory meatus and on the tympanic membrane. 

According to Litten,^ severe attacks of epistaxis occur 
in scorbutus, which require tampons to control the hemor- 
rhage and may lead to a fatal issue. The hemorrhage is 
said to be more apt to occur after a slight injury to the 
nasal mucous membrane or violent blowing of the nose 
than spontaneously. 

Truckenbrodt "^ reports the autopsy of a man who had 
died of scorbutus ; the patient had not been examined in 
vivo, but had never complained of tinnitus or pain in the 
ear. An extravasation of blood was found in the dermic 
layer of the right tympanic membrane ; the mucous mem- 
brane of the middle ear was puckered and contained a 
hemorrhage, and a few petechial hemorrhages were found 
in the mastoid antrum. 

1 Schmidt's "Jahrb.," CCXL, p. 244. 

2 " Semon's Centralbl. f. Laryng.," 11, p. 476. 

3 " Deutsches Arch. f. klin. Med.," vol. XXXIX, p. 467. 

4 Schwartze's " Handb.," I, p. 547. 

5 '< Die Krankh. des Ohres," p. 178. 

6 Nothnagel's " Spec. Path. u. Thar.," viu, i. Th., p. 298. 
^ "Arch. f. Ohr.," xx, p. 265. 



V. CHRONIC CONSTITUTIONAL DISEASES. 



J. RACHITIS. 



It has always been the custom to regard laryngeal spasm 
as a symptom of rachitis, but in recent years a literary con- 
troversy was provoked by the writings of Escherich and 
Loos,i and there is now a movement in favor of treating 
laryngeal spasm as a symptom of tetany, denying any 
etiologic relation with rachitis. 

An analysis of all reported cases, however, shows 
beyond a doubt that rachitis exists in the great majority 
of cases of laryngeal spasm, — three-fourths of all cases 
according to some authorities, 90^ according to others, — 
and it is preposterous to ascribe this coincidence entirely to 
accident. Loos himself, although he denies any causal 
relationship, states that the children affected with spasm of 
the glottis " as a rule exhibit distinct signs of rachitis." 

Laryngospasm, or spasm of the glottis, is an expiratory 
apnea occurring usually in children under two years of age. 
The attacks come on suddenly, without ascertainable cause, 
last from a few seconds to about half a minute, and end 
abruptly, with a deep whistling or with several rapid, 
superficial inspirations, after which quiet breathing is re- 
stored. The child assumes a rigid attitude, with head 
thrown back, eyes fixed and staring upward, arms extended, 
and hands clenched ; the face becomes cyanotic and wears 
a look of extreme fright — in short, we have the terrifying 
picture of complete asphyxia. But the attack, although it 
seems very alarming, usually subsides, and only in rare 
instances terminates fatally. 

The whole clinical picture shows that we have more 
than a simple spasm of the adductors of the vocal cords 
to deal with, in which the dyspnea is due solely to occlusion 
of the glottis. In the latter form — which we observe, for 
instance, after endolaryngeal interference — the integrity 

1 '• Deutsches Arch. f. klin. Med.," vol. L. 
92 



RACHITIS. 93 

of the respiratory muscles is retained, as we see by the dis- 
tinct voluntary inspiratory movements ; but in laryngismus 
stridulus of infants the expiratory muscles and the dia- 
phragm are also involved in the spasm. It is, therefore, not 
a spasm of the larynx, but, to quote Rehn,i a spastic 
symptom-complex, for which no appropriate name has 
as yet been discovered. The term " tetanus apnoicus 
infantum," suggested by Elsasser,^ has the objection, in 
these days of controversy on the subject of tetany and 
rachitis, of appearing to take the etiology for granted ; and 
Oppenheimer's 3 "asthma rhachiticum," while it has the 
same objection, is also misleading, as the condition it is in- 
tended to designate in no way resembles asthma. 

Laryngoscopic examination during the attack is out of 
the question, and the assumption that the glottis is convul- 
sively closed during the attack rests on a purely speculative 
basis. Schrotter, * who is an adept in laryngoscopic 
technic, says that spasm of the glottis is not a subject for 
laryngoscopic examination, from which it may be inferred 
that he never saw a laryngeal image in this affection, and 
it is therefore the more surprising that Lori,^ without even 
alluding to the difficulties attending the examination, and 
the possibility of failure, gives the following description : 
" During the attack I always found the rima glottidis tightly 
closed, but the closure in every case was effected by the 
true vocal cords alone, without the aid of the false cords. 
The epiglottis was always depressed, as is constantly the 
case in very young children, except when they are crying 
in a very high key, or choking or drawing breath with a 
whooping sound ; but the depression was never complete, 
so that in most cases I could see the posterior segments of 
both vocal cords, and in some instances the entire posterior 
half. I have never seen the epiglottis wedged in between 
the arytenoid cartilages." 

Various views have been advanced on the mode of origin 
of spasm of the glottis. Some seek the cause in rachitic 
changes and the rachitic diathesis ^ ; others in disturbances 

1 " Berlin, klin. Wochen.," 1896, No. 33. 

2 Quoted by Flesch, " Gerh. Handb. der Kinderkrankh.," p. 289. 

3 " Deutsches Arch. f. klin. Med.," .XXI, p. 559. 

4 " Krankh. dcs Kehlkopfes," 1st ed., p. 386. 

^ "Veranderungen des Rachens, des Kehlkopfes und der Luftrohre," p. 99. 
^ Kassowitz, " Wien. med. Wochen.," 1893, P- 545- Vierordt, Noth- 
nagel's " Spec. Path. u. Ther.," vol. vii, i. Th. 



94 CHRONIC CONSTITUTIONAL DISEASES. 

of the digestion ^ more or less closely dependent on rachi- 
tis ; still others in a nervous predisposition ^ ; and some, 
finally, reject rachitis altogether and attribute the phenom- 
enon to tetany.^ 

Rehn takes a middle view, and attributes the spasm to 
irritation of the sensory fibers of the vagus by toxins elab- 
orated in the stomach as the result of faulty metabolism. 
As the origin of this symptom-complex — which, although 
its etiology is still very obscure, has been termed infantile 
tetany — has been thought by some authorities to be due 
to the action of toxins manifesting itself in digestive dis- 
turbances, we see in this proposition of Rehn's the possibility 
of a uniform etiology for that hitherto antagonistic tripod — 
rachitis-laryngospasm-tetany. 

It is admitted by everybody that malnutrition is a pre- 
disposing factor, or even an exciting cause, of spasm of the 
glottis, and it has been found by experience that the most 
successful treatment of laryngospastic attacks consists in 
regulating the nutrition. 

Since the spasm is not limited to the larynx, but merely 
forms a part of the general convulsions which play so im- 
portant a part in rachitis, it can not be regarded as the 
effect of irritation of a definite portion of the peripheral or 
central nerve paths presiding over the action of the laryngeal 
muscles ; and until the etiology is better understood, it is 
idle to suppose a cortical irritation or a lesion in the me- 
dulla or in the pneumogastric. There is little foundation 
either for Kassowitz's theory that spasm of the glottis is 
due to irritation of the cortical centers (described by Semon- 
Horsley, Krause, and Unverricht-Preobraschensky) by a 
hyperemic, inflammatory condition of the rachitic cranial 
bones, or for that of Oppenheimer, which assumes some 
irritative action of the jugular vein on the vago-accessorius 
nucleus due to rachitic alterations at the jugular foramen. 
The most we can say is that spasm of the glottis in chil- 
dren is the expression of an abnormal excitability of all the 
respiratory muscles, and that it often occurs, in association 
with tetanic symptoms (Chvostek, facial nerve phenome- 

1 P'lesch, "Spasmus glottidis," in " Gerh. Handb. der. Kinderkrankh.," 
1879. Rehn, " Berlin, klin. Wochen.," 1896, No. 33. Hauser, " Berlin, klin. 
Wochen.," 1896, No. 35. 

^ Flesch, "Spasmus glottidis," in "Gerh. Handb. der Kinderkrankh.," 
1879. 

3 Loos, " Deutsches Arch. f. klin. Med.," L, p. 169. 



RACHITIS. ACROMEGALY. 95 

non), in rachitic subjects as the result of digestive dis- 
turbances. 

Of the relations between racliitis and aural disease noth- 
ing positive is known. The attempt to establish a connec- 
tion between the former and purulent or catarrhal disease 
of the middle ear has been made, but there is not a shadow 
of proof to justify it. Such superficial statements as those 
made by Ertelberg, and faithfully repeated by Haug, are 
of no value whatever; for the mere fact that among 250 
rachitic children there were 25 cases of middle-ear disease 
and only 27 absolutely normal tympanic membranes,^ 
especially when the histories were not altogether negative 
in the matter of previous infectious diseases, or that " among 
180 rachitic children purulent otitis media was found 16 
times, otitis externa twice, eczema 9 times, otitis media 
catarrhalis 19 times, and catarrh of the tubes even more 
frequently" (Haug^), is not in the least significant, as the 
same conditions are found, even without rachitis, in the 
children who make up ordinary polyclinic material. 

It is quite possible that the general nutritive disturbances 
and frequent attacks of bronchial catarrh which characterize 
the course of rachitic disease tend to produce a favorable 
soil for the development of aural complications, but we are 
very far from possessing any scientific proof that such is 
actually the case. 



2. ACROMEGALY. 

In acromegaly ^ a hyperplasia of the submucous and 
intermuscular connective tissue takes place, which pro- 
duces certain alterations in the bones and cartilages. These 
changes affect more or less the nose, pharynx, and larynx, 
and to some extent the ears. 

Besides the external changes in the nose, which consist 
in an abnormal increase of the cartilaginous and bony por- 
tions, there is hypertrophy of the nasal mucous membrane. 
The tongue becomes enormously enlarged, and hyperplasia 
of the submucous tissue in the soft palate takes place. The 

1 " Jahrb. f. Kinderheilk.," xxvii, p. 96. 

2 " Die Krankh. des Ohres," etc., p. 173. 

3 Sternberg, " Zeitschr. f. klin. Med.," xxvii, p. 86. Sternberg, Noth- 
nagel's " Spec. Path. u. Ther. ," vii, 2. Th. 



96 CHRONIC CONSTITUTIONAL DISEASES. 

larynx is increased in size, as we can determine by external 
palpation, and the voice is unusually deep and rough and 
is stronger than normal. As there is no visible alteration in 
the laryngoscopic image, these phenomena are probably 
due to the general enlargement of the larynx, to hyper- 
trophy of the mucous membrane, and in part to increased 
resonance of the voice from the greater volume of air in the 
chambers of the upper air-passages (Marie). 

Sternberg ^ describes diminutions in the caliber of the 
external auditory vieatus from exostoses, quotes similar ob- 
servations by Osborne, and adds that the bony portion of 
the meatus was unusually deep on account of hyperostosis of 
the bony parts of the skull. As these alterations have been 
found in acromegalic skulls in several instances, Stem- 
berg believes himself justified in including them among the 
constant objective symptoms of the disease. 



3, DIABETES MELLITUS. 

In diabetes the dryness of the oral mucous membrane of 
which the patients complain finds its counterpart in a dry 
pharyngitis with redness of the mucous membrane, which, 
Hke chronic pharyngitis, is regarded by M. Schmidt^ as an 
early symptom of the disease. Lori ^ claims that the same 
condition of dr>^ness and atrophy may be found in the 
larynx. In this connection it is worth mentioning that 
aphasia has occasionally been noted in association with 
diabetic hemiplegia"* ; F. A. Hoffmann ^ includes paralysis 
of the vocal cords among diabetic palsies, but I have not 
been able to find any case of it in the literature. 

Furunculosis and pruritus occur in the auditory meatus 
as they do in the external skin (Wolf,^ Haug'^). If the 
former recurs frequently, it is said to be a sign of diabetes ; 
but the diagnostic value of this statement is open to ques- 
tion when we contrast the frequency of furunculosis in the 

1 " Zeitschr. f. klin. Med.," xxvii, p. 139. 

2 " Krankh. d. ob. Luftwege," 2d ed., p. 226. 

3 " Veranderungen des Rachens und Kehlkopfes," p. 97. 

•* Charcot, "Arch, de neurolog.," May, 1890. Blanchet, " Gaz. des 
hopit.," 1885. 

■^ " Constitutionskrankheiten," p. 316. 

« "Arch. f. Ohr. ," p. l66. ' " Die Krankh. des Ohres," etc. 



DIABETES MELLITUS. 9/ 

ear with the rarity of furunculosis of the auditory meatus 
in diabetes. I have never observed it myself, nor seen it 
mentioned in any good case history. Blau^ reports a case 
in which attacks of furunculosis kept recurring for years 
without his ever being able to demonstrate any signs of 
diabetes. Neuralgia of the mastoid process is mentioned 
among the complications of diabetes by Brieger^ ; it is, 
however, of secondary importance. 

On the other hand, the middle ear and mastoid cells are 
sometimes attacked by a disease which presents certain 
characteristic appearances, and justifies the assumption that 
it is more or less closely related to diabetes. Toynbee de- 
scribes a case of suppuration of the mastoid process in 
which extensive carious destruction of the structure was 
found after death, without, however, referring it to the dia- 
betes which was present at the same time. How recent 
our knowledge of diabetic ear disease really is appears from 
the remarks of Senator^ and Blau, published in 1876 and 
1883 respectively, to the effect that loss of hearing and 
implication of the organ of hearing generally must be very 
rare in diabetes, to judge from the lack of reported experi- 
ences. Naunyn,* on the contrary, in his recently published 
work on diabetes devotes an entire section to diabetic ear 
diseases, showing how much our knowledge of such com- 
plications has advanced in the short space of twelve years. 
To Kirchner,^ and even more to Kuhn^ and Korner,'^ we 
owe the first discussions on the subject, and to-day we have 
a goodly number of instructive observations at our disposal 
which afford certain definite conclusions. The disease is 
characterized by the sudden onset of violent pain, localized 
in the ear or, more frequently, in the mastoid. The 
patients are usually quite unable to give any cause for the 
pain. In some cases the affected ear was quite healthy 
before the attack ; in others, there is a history of antecedent 
purulent otitis media. After a longer or shorter interval of 
pain, usually on the third to the fifth day, perforation takes 
place spontaneously and pus is discharged. The secretion 
contains nothing that may not be present in any acute sup- 



" Arch. f. Ohr.," xix, p. 208. - " Klin. Beitr. f. Ohr.," p. 115. 

In Ziemssen's " Handbuch." 

Naunyn, Nothnagel's "Spec. Path. u. Ther.," vol. vii, 6. Th. 
"IMon. f. Ohr.," 1884, p. 221. 

" .\rch. f. Ohr.," xxix. '' " Arch. f. Ohr.," xxix. 

7 



98 CHRONIC CONSTITUTIOXAL DISEASES. 

puration of the middle ear. It may be a mixture of blood 
and serum, seropurulent, or, in a long-standing case, muco- 
purulent. Raynaud's 1 case began as a copious hemor- 
rhage from the auditory meatus, which was followed by 
such an abundant flow of serosanguineous, and later serous, 
secretion, " as is ordinarily seen only in the discharge of 
cerebro-spinal fluid after trephining," and finally went on 
to the purulent stage. 

In a remarkably short time the morbid process in diabetic 
otitis spreads to the bones. The rapidity with which the 
disease is followed by carious disintegration of the mastoid 
cells is commented upon by Toynbee and, after him, by 
many other observers ; it is even greater, according to 
Kuhn, than in the most malignant cases of diphtheria. 
Within the short space of two or three days the interior of 
the mastoid process in many cases is converted into a large 
cavity, filled with pus and granulations mixed with seques- 
tra of bone, and in a few weeks the transverse sinus and 
dura mater of the posterior fossa of the skull are laid bare. 
Raynaud found, when his case came to the autops}% the 
mastoid cells filled with a reddish fluid mixed with inspis- 
sated pus, while the mucous membrane was soft and red ; 
in Kuhn'scase the bony parts that had escaped destruction 
were inflamed and so soft that they could be molded and 
cut like wax. I myself operated on two cases in which 
the spongy tissue was much discolored and scantily 
streaked with pus ; the bone was very anemic and brittle 
from necrosis, suggesting the appearance of a preparation 
which has been in alcohol for a long time. In several 
places there were large sequestra, which could be easily 
removed from the surrounding tissue. 

Are these clinical pictures such as to justify the assump- 
tion of a diabetic form of middle-ear disease, since their 
only deviation from an ordinary case of purulent otitis 
media lies in the rapidity of the course and the early 
implication of the bone ? We can not deny that this is 
an important element, in spite of Brieger's ^ opinion that 
the intensity of the process is not sufficient warrant for 
assuming the existence of a special form of disease. Haug ^ 
tested the aural secretion for sugar, and found it " at least 
qualitatively " positive (by what methods ?) ; Raynaud, on 

1 " Ann. des mal. de I'oreille," 1881, p. 63. 

2 " Klin. Beitr. zur Ohrenheilk.," p. 112. ^ Lg^^ ^it., j). 166. 



DIABETES MELLITUS. 99 

the Other hand, found albumin, but no sugar, in the serous 
secretion. As the most various secretions and excretions 
of the body have been found to contain sugar in diabetes, 
Haug's positive results can not weigh very heavily, while 
Raynaud's negative result is interesting from the fact that 
an examination of the fluid taken from the edematous 
scrotum in the same case showed 0.7^ sugar. 

The point at which perforation of the tympanic mem- 
brane occurs varies, and is of no value for diagnosis, as it 
occurs indifferently in the anterior or posterior half of the 
membrane (Raynaud). 

The course of the suppurative process is characterized, 
as has been stated, by rapidity of extension to the bone. 
Arguing from the extensive and rapid destruction of the 
mastoid processes, with comparatively mild disease of the 
middle ear, Kuhn and Korner have advanced the opinion 
that the process in diabetic ear disease begins as a primary 
osteitis of the mastoid, and extends secondarily to the tym- 
panum, thus bringing about perforation. 

It is quite natural that the original opponents of the 
doctrine of a primary mastoid osteitis should oppose such 
an assumption, but they were reinforced by others (David- 
son i), who based their objections on a review of the liter- 
ature. 

In favor of Kuhn's theory we have the clinical features 
and course of the disease, especially the circumstance 
(insisted on by Korner) that the changes found in the 
middle ear bear no proportion to the intense degree of 
destruction in the mastoid process, and the flow of pus 
subsides as soon as the diseased bone is opened, as I have 
myself observed in one of the patients I operated on. 
Another argument in favor of Korner's view is found in 
the necrotic, gangrenous appearance of the bone, which I 
have mentioned, and which was equally marked in both 
my cases ; a dry, gangrenous appearance of the tissues 
being a well-recognized feature of the diabetic diathesis. 

On the other hand, it may be urged against the fore- 
going theory that the resisting power of the tissues to 
bacterial invasion is diminished by the presence of sugar, 
which affords a favorable soil for the growth of pathogenic 
micro-orcranisms. so that an accidental infection of the mid- 



1.^4 



Berlin, klin. Wocben.," 1894, No. 51. 



lOO CHRONIC CONSTITUTIONAL DISEASES. 

die ear finds the most favorable conditions for the spread 
of the disease. The comparative benignity of the middle- 
ear affection can be explained by the drainage facilities 
through the perforated membrane, which are wanting in 
the mastoid cells, where the carious process accordingly 
continues its work of destruction. It should also be 
said, in justice to the opponents of a primary osteitis, that 
there are cases in which the bone disease appeared late in 
the course of a chronic purulent otitis media, just as there 
are others in which an acute suppuration terminated favor- 
ably without involving the mastoid cells. 

In this connection a case of Naunyn's ^ is peculiarly in- 
teresting. In a severe case of diabetes a violent otitis media 
developed on the fourth day ; the patient, a boy of eight, 
complained of severe headache, and there were marked 
cerebral symptoms, with vomiting, great hebetude, and 
" large respiration, as in diabetic coma," Paracentesis was 
performed on the fifth day and a large quantity of pus was 
evacuated ; recovery followed in a few days. I once saw 
a similar case in a boy of fourteen, with grave diabetes, 
who experienced pain in the ear and a slight otorrhea two 
days before the occurrence of diabetic coma. On the fol- 
lowing day, while the coma continued, the flow subsided, 
and the ear-drums, which were perforated and showed the 
scars of former lesions, were seen to be slightly swollen 
and of a uniform bluish-red color, which soon disappeared. 
Six months later, the same ear was attacked by acute 
middle-ear inflammation, necessitating paracentesis ; after 
the discharge had lasted about a week the patient again 
recovered. 

In reviewing the facts before us, it appears that there are 
unquestionably cases of simple diabetic otitis which prove 
the existence of a diabetic disease localized in the middle 
ear ; but it is equally certain that there are many cases, 
reported by Kuhn, Korner, and others, which as emphat- 
ically justify the assumption of a primary osteitis, espe- 
cially since we possess the description of a case of diabetic 
osteitis and multiple periosteitis elsewhere in the body, 
which confirms the possibility of such primary bone disease 
in diabetes. 

Ho\ve\'er that may be, whether we have to deal with a 

1" Diabetes" in Nothnagel's " Spec. Palh. u. Then," p. 287. 



DIABETES MELLITUS. 1 01 

primary osteitis or a primary otitis media, the occurrence of 
suppuration from the ear in diabetes constitutes a grave 
compHcation, which must be combated from the outset with 
all the means at our command. There was a time when 
operative treatment of diabetic otitis media was thought to 
be contraindicated, because a few deaths had been reported. 
If the wound is properly treated, this fatal result must be 
charged to postoperative diabetic coma (two out of four 
cases by Bucki), and not, so far as I can see, to the opera- 
tion itself^ (one case reported by Sheppard died of inter- 
current erysipelas and purulent meningitis 3). As it is well 
known that the morbid process in the bone spreads very 
rapidly in diabetes, without giving rise to any pronounced 
subjective symptoms, trephining of the mastoid process is 
indicated whenever the ominous sinking of the posterior wall 
of the meatus has been present for some time, or deep ab- 
scesses have made their appearance in the mastoid process 
itself. A liigli sugar percentage is, however, an absolute 
contraindication, as it enhances the danger of postoperative 
diabetic coma ; this is probably the direct result of chloro- 
form narcosis, which is followed by a rise in the percentage 
of sugar, as observed in Korner's cases and in my own that 
terminated favorably (from 0.2 to 1.85^ in my cases). 
Since, therefore, the danger lurks in the anesthesia as well 
as in the operation itself, one should never operate without 
first reducing the sugar as much as possible by a long 
course of dieting. Recent experience teaches that in this 
way we also diminish the danger of sepsis, which, according 
to Schwartze,^ " renders the prognosis as to life a doubtful 
one, even in mild grades of diabetes, because there is 
danger of an unfavorable postoperative course, ending in 
sepsis." At all events, it is not great enough to forbid 
operative interference, any more than the imaginary danger^ 
of uncontrollable hemorrhage, which appears to be founded 
on a case of Moos,"^ in which "the operation was inter- 
rupted by an uncontrollable hemorrhage, lasting three-quar- 
ters of an hour" — its origin is not stated, and who is to say 
that it was due to the diabetes ? 

1 "Arch. f. Ohr.," XL, p. 138. 

2 I recently saw a death during coma on the fourth day after the operation ; 
nt the autopsy a large abscess was found in the deep muscles of the neck. 

3 " Zeitschr. f. Ohr.," xxix, p. 268. 

•* " Handb.," 11, p. 841. * Haug, " Krankh. des Ohres," p. 167. 

6 " Deutsche med. Wochen.," 1888, No. 44. 



102 CHRONIC CONSTITUTIONAL DISEASES. 



4. GOUT, 

The most familiar examples of gouty alterations are the 
catarrhal phenomena in the pharynx and larynx. They 
occur most frequently in the form of angina uratica, with 
dark-red discoloration of the mucous membrane of the 
uvula, soft palate, the two pillars of the fauces, and the 
tonsils. Sometimes an acute edema is superadded, as has 
been observ^ed by Vaton,i M. Mackenzie, ^ and Danziger. ^ 
Solis-Cohen * insists on the frequency of pains and abnor- 
mal sensations in circumscribed areas of the mucous mem- 
brane which appeared to be perfectly healthy, and in which 
he found only dilated vessels or a dark-red discoloration. 
Acute attacks of angina uratica always make their appear- 
ance two or three days before a typical outbreak of gout, 
and subside as soon as the gouty joint-affection has 
declared itself There is also, as a rule, chronic pharyn- 
geal catarrh, associated sometimes with tophi (Litten^). 

Gouty disease of the larynx is rarely observed. It mani- 
fests itself in a great variety of forms, the inflammatory 
redness and swelling being often attended with the deposi- 
tion of urates in the joints and cartilages. The mucous 
membrane of the vocal cords is involved, as well as that of 
the rest of the larynx, and not infrequently there are cir- 
cumscribed swellings in special portions of the larynx. 
Thus, in a gouty patient I have seen an infiltration of the 
right ventricular band persist for many years following a 
laryngitis which had come on after an acute attack of gout. 
M. Mackenzie ^ observed a gouty inflammation of the left 
false vocal cord, with granulations, which had been diag- 
nosed as cancer. Virchow,' Litten, Morell, and Mac- 
kenzie saw gouty deposits : in one case a white body as 
large as the head of a pin, at the posterior extremity of the 
right vocal cord ; at other times, as infiltrations in the cords 
and articulations of the larynx. In Mackenzie's case it was 
the crico-arytenoid articulation that was affected, and the 
resulting imperfect approximation of the vocal cords gave 
rise to aphonia. Litten found postmortem marked infiltra- 



137- 



^ "Semon's Centralbl.,' 


VIII, p. 85. 




* " Journ. of Laryngol., 


' 1889, p. 313. 




3 " Mon. f. Ohr.," 1895, 


p. 14. 




* " Semon's Centralbl.,' 


XI, p. 318. 5«Virch. Arch.,' 


' 66. 


6 Loc. cit. 


' " Virch. Arch., 


' 44, P 



GOUT. 103 

tion of the same joints and their hgaments (the cHnical 
appearance of the larynx is not given). The gouty process 
in the cartilages not infrequently goes on to ossification. 

Of the gouty alterations in the organ of hearing those 
which affect the concha have been known a long time, and 
every physician is familiar with them. In nearly all of 
Garrod's ^ case histories we find mention of small gouty 
nodules in the concha, sometimes on the posterior surface, 
more commonly on the helix and fossa navicularis. The 
cartilage is said to be the seat of a peculiar induration and 
of the formation of small softening foci. In some cases 
there is inflammation of the external auditory meatus (pru- 
ritus). The statement that exostoses in the external meatus 
are due to gout (Kirchner) has never been proved. Judg- 
ing from the frequency of complaints from arthritic patients 
to the effect that they suffer from difficulty in hearing, 
especially progressive loss of hearing and tinnitus, we must 
infer that other lesions occur in the organ of hearing. We 
are not inclined to accept angina as the explanation of the 
loss of hearing in gouty subjects, as suggested by Haug ; 
for there really is not any form of aural complication that 
might not occasionally be referred to a hypertrophic phar- 
yngeal catarrh. Ebstein's arguments in his treatise on 
"Aural Vertigo" seem to us more plausible. 2 

The clinical picture of gouty ear disease, which, as has 
been said, has for its principal features a progressive dimin- 
ution of the hearing, with tinnitus and vertigo, may be ex- 
plained in as many different ways as there have been causes 
assigned for gout itself. It is still a question whether the 
gouty process is in the middle or in the internal ear ; we 
can not say positively that the chalky deposits seen during 
life on the tympanic membranes of gouty subjects consist 
of urates, for the manner in which the morbid process 
affects the organ of hearing is very imperfectly understood. 
A specific gouty affection of the organ of hearing may be 
situated in the tympanic membrane, where the resulting 
functional disturbance would probably be slight, or in the 
chain of ossicles in the form of arthritic disease. Unfortu- 
nately, we are without anatomic experience on this point, 
and even the clinical stock of observations at our command 
is ver}^ limited. A case history, to have any statistical 

1 Deutsche Uehersetzung von Eisenmann, p. loi. 
^" Arch. f. klin. Med.," 58, p. I. 



104 CHRONIC CONSTITUTIONAL DISEASES. 

value in showing a connection between gout and diseases 
of the middle ear, should contain not only the results of 
an accurate functional examination, but also some infor- 
mation in regard to the movability of the chain of ossicles. 

Brieger ^ reports a case in which the usual prodromata 
of an attack of gout were followed by an acute otitis media, 
with marked bulging and swelling of the tympanic mem- 
brane, and interprets it as an arthritic process in the artic- 
ulation, between the malleus and incus. According to 
Agnano,2 persons with the gouty diathesis usually develop 
deafness between the ages of fifteen and twenty. 

Still more uncertain are we whether the labyrinth is ever 
attacked by the gouty process. Since the imaginary hem- 
orrhages which are sometimes supposed to form the basis 
of the phenomena in the labyrinth, mentioned previously 
under the name of Meniere's symptom-complex, must be 
rejected as being without anatomic foundation, the most 
natural explanation of these symptoms is suggested by the 
vascular changes which are a constant feature of gout, and 
we are therefore inclined to seek the cause of these aural 
phenomena in a primary arteriosclerosis. This view ap- 
pears to be supported not only by the observations of 
Ebstein, but also by de Lacharriere's statement that "aural 
phenomena are most common in persons who, besides being 
subject to attacks of genuine articular gout, show their in- 
herited gouty tendencies in attacks of gastralgia, dyspepsia, 
migraine, and neuralgia." Ebstein is right, no doubt, 
when he says that it must, for the present, remain an 
open question whether the ear disease in gouty subjects is 
to be referred to the primary disease, to obesity, or to car- 
diac changes the result of overindulgence in alcoholic 
beveraees. 



ICTUS LARYNGIS OCCURRING IN THE [COURSE OF 
OBESITY, GOUT, AND DIABETES. 

That there is a certain relationship between the three 
constitutional anomalies, obesity, gout, and diabetes, ap- 
pears from the way in which they manifest themselves 
in individual members of a gouty family — now under one 
form, now under another. They produce chronic catarrhal 

1 " Klin. Beitr. zur Ohrenheilk.," p. 77. 

2 " Rev. hebd, de lar.," 1896, p. 703. 



ICTUS LARYNGIS. IO5 

changes in the mucous membranes of the upper air-pas- 
sages, and a peculiar form of neurosis in the larynx, which 
has been called " ictus laryngis." Their relation to aural 
vertigo, tinnitus, and progressive chronic loss of hearing 
has been sufficiently discussed under the head of gout, 
where reference was made to Ebstein's treatise on the sub- 
ject. 

We shall, however, give a short description of what 
is known as " laryngeal vertigo," a condition which more 
frequently comes under the observation of the general 
practitioner than that of the laryngologist. 

By ictus laryngis is meant a sudden attack of syncope of 
short duration, preceded usually by a slight paroxysm 
of coughing. It was first described by Charcot in 1876, 
then by two French writers, Garel and Collet, and by the 
Italian, Massei, while in Germany up to the present 
time only a very few observations have appeared (for in- 
stance, Schadewaldt's). Charcot proposed the term vcrtige 
larynge, and it is still found in many text-books on laryn- 
gology, although vertigo itself is one of the rarest features 
in the symptom-complex ; Kurz's suggestion of lipothymia 
laryngea (laryngeal syncope) ^ has not met with a very 
favorable reception. The term laryngeal crisis, which has 
also been suggested, would only cause a confusion of ideas, 
because it is applied to an entirely different symptom-com- 
plex, which, as we shall see, is peculiar to tabes dorsalis. 

The attack occurs without warning in the midst of per- 
fect health ; it may come on while the subject is working, 
sitting, standing, walking, or even lying dow^n. Quite fre- 
quently the attack comes on after a meal ; sometimes the 
patient is aAvakened at night by a slight cough, sits up 
in bed, and has an attack. The description usually given 
is that the patient feels a tickling sensation in the throat, has 
a slight attack of coughing, and loses consciousness for a 
few seconds ; the breathing stops and the face becomes 
cyanotic. If the subject is standing at the time, he falls to 
the ground ; if he is sitting, the head falls forward on the 
chest. In a few instances the attack was attended with 
twitching in the muscles of the upper extremity or of the 
face, but never with biting of the tongue. The duration is 
very short, — usually a few seconds ; the patient does not 

1 " Deutsche med. Wochen.," 1S93. 



I06 CHRONIC CONSTITUTIONAL DISEASES. 

feel unwell after it is over, and goes on with whatever 
he is doing at the time as if nothing had happened. When 
questioned, he says he has had an attack of coughing, but 
does not complain of any other symptom. 

The cases reported nearly all refer to men in the fifth 
decade of life. The predisposing causes usually given are 
chronic catarrh of the upper air-passages, chronic phar- 
yngitis and laryngitis, occasionally chronic catarrh of the 
lungs. Schadewaldt emphasizes chronic alcoholism as a 
predisposing factor, while Garel and Collet attach great 
importance to constitutional diseases, as gout, obesity, and 
diabetes. Cardiac changes play an important role : Schade- 
waldt found the heart hypertrophied (cor adiposum) in five 
of his seven cases. The clinical picture aroused the suspi- 
cion in the minds of the observers that they had to deal with 
an epileptic attack, but subsequent experience has failed to 
establish any connection whatever with epilepsy. From 
the fact that an attack can be brought on by introducing a 
sound into the larynx, and controlled by cocainizing the 
mucous membrane, it was argued that it must be a kind of 
reflex neurosis, but the descriptions offered for the reflex 
arc rest on a purely hypothetic basis. It seems to be 
proved by the fact that the attack begins with a tickling 
and burning sensation in the throat, that it is due to irrita- 
tion of the superior laryngeal nerve. This being the case, 
it is supposed that the vasomotor center in the medulla is 
stimulated through the depressomotor fibers of the vagus, 
and a fall in the blood pressure takes place ; at the same 
time the irritation is communicated to the cardiac inhibitory 
center, so that the action of the heart is diminished. These 
two factors cooperating to produce anemia of the brain, 
furnish an explanation of the loss of consciousness, which 
is characteristic of the attack. 

Spastic phenomena are altogether wanting, although 
some observers attempt to explain the attacks as laryngeal 
spasm, and it is doubtful whether we are, after all, justi- 
fied in regarding ictus laryngis as a local neurosis of the 
larynx. The circulatory system unquestionably plays an 
important part in the etiology, for many of the cases were 
complicated with heart disease, and a marked predisposi- 
tion to the attacks was observed in plethoric persons and in 
those addicted to good living and alcoholic abuse. The 
frequent occurrence of the attacks during the digestive 



ICTUS LARYNGIS. lO/ 

pause immediately following a meal also points to the cir- 
culatory system. Schadewaldt reports a case which ended 
fatally ; the patient had had an attack of ictus laryngis on 
the previous day, after supper, but felt so well on the day 
of his death that he took his customary horseback ride. 
In the afternoon, however, while engaged in conversation 
with a companion, he had another slight attack of coughing, 
lost consciousness, fell to the ground, and died instantly, 
without exhibiting any other symptoms. No autopsy is 
given, but the history of cardiac hypertrophy in a robust, 
alcoholic individual, fifty-nine years old, justifies the diag- 
nosis of death from heart failure. 



VI. ACUTE INFECTIOUS DISEASES. 



J. MEASLES. 

Catarrhal disease of the mucous membranes in the 
upper air-passages constitutes an integral part of the chnical 
picture in measles. It takes the form of an exanthema, 
which always precedes the skin eruption, and is absent, ac- 
cording to Monti, 1 only in children who are very anemic 
or weakened by previous disease. 

Even during the prodromal stage of measles there is a 
dark-red discoloration of the pharynx and palate ; it is 
irregularly distributed, and is most marked on the lateral 
and posterior pharyngeal walls and on the pillars of the 
fauces. The discoloration is also seen on the mucous mem- 
branes of the cheeks and lips, where it constitutes Koplick's ^ 
sign. The redness is accompanied by a feeling of dryness 
in the throat ; on the following day the mucous membrane 
appears moist and the true exanthema begins to break out. 
This exanthematous eruption is most marked on the pillars, 
where it takes the form of small isolated or confluent 
macules or papules of varying size, elevated above the level 
of the mucous membrane (Monti). The skin eruption 
appears usually from twelve to twenty-four hours later, and 
with its appearance the patches begin to subside. In addi- 
tion to the redness and swelling, Tobeitz ^ observed a super- 
ficial slough, resembling that produced by a mild caustic, 
which he interprets as an epithelial necrosis. Similar 
appearances are seen in the larynx ; they also accompany 
other catarrhal diseases, particularly influenza. 

The mucous membrane of the larynx presents a bright- 
red color, in irregular patches, interspersed with fine granu- 
lar nodules (Gerhardt). This variety of laryngitis usually 
appears two or three days after the exanthematous erup- 

1 " Jabrb. f. Kinderheilk.," vi, p. 22. 

2 " Deutsche med. Wochen.," 1898. 

* "Arch. f. Kinderheilk.," vni, p. 326. 
108 



MEASLES. 109 

tioii, seldom later, and gives rise to hoarseness and cough 
of a croupy character. The patches of epithelial necrosis 
mentioned by Tobeitz take the form of erosions and shallow 
ulcerations on the posterior pharyngeal wall, and are sup- 
posed by Gerhardt to be due to mechanical injury of the 
already loosened mucous membrane by the act of coughing. 

Croupous laryngitis is a rare occurrence in measles. To- 
beitz saw evidences of very mild forms at autopsies, not 
severe enough to cause stenosis, rather a shallow croupous 
deposit ; the mucous membrane in these cases was of a 
bright-red hue, but not much swollen, and the surface was 
deprived of its epithelium and in places necrotic. Compli- 
cations of measles with diphtheria and true diphtheric 
laryngitis are not unknown. 

Thanks to trustworthy anatomic investigations, our 
knowledge of ear diseases in the course of measles is more 
complete than is the case in the other infectious diseases. 
To Tobeitz, Rudolf, Bezold, and Habermann we are in- 
debted for investigations on the cadavers of children which 
give us uniform results concerning the nature and mode of 
spread of aural complications in measles. One valuable 
feature of these investigations — especially of Bezold's, who 
examined a large number of cadavers — is the fact that par- 
ticular attention was paid to the organs of hearing in those 
cases which during life had presented few, if any, symptoms 
of disease, so that an opportunity was afforded of studying 
the earliest stages of the alterations. 

In 16 cases examined by Rudolf (and tabulated under 
Bezold's direction), 17 by Bezold ^ himself, 17 others by 
Tobeitz, 2 6 by Siebenmann,^ and 7 by Habermann, ^ with 
only two exceptions there were found signs of an aaite 
otitis media, which must be regarded as a special localiza- 
tion of the disease. It was found to persist for some time 
after the appearance of the eruption, for Bezold's cases 
belong to the period from the third to the thirty-third day 
of the disease. 

According to Bezold's description of these early appear- 
ances in disease of the middle ear — and they can frequently 
be demonstrated in the first three days after the appearance 

1 "Zeitschr. f. Ohr.," xxviii, p. 209. 

2 "Arch. f. Kinderheilk.," in, 341. 

3 Quoted from Bezold, " Zeitschr. f. Ohr.," vol. xxviil, p. 249. 
* " Schwartze's Handb.," vol. i, p. 261. 



IIO ACUTE INFECTIOUS DISEASES. 

of the eruption — there is a diffuse injection and turgescence 
of the mucous membrane, and the tympanic cavity contains 
more or less fluid. It is an important point that the dis- 
ease also extends to the lining of the mastoid antrum and 
cells. 

The secretion in the tympanic cavity was never of the 
purely serous type found in simple occlusion of the tubes, 
but was mucopurulent or seropurulent or consisted of pure 
pus. The injection of the blood-vessels was irregularly 
distributed over the mucous membrane in the form of 
patches and minute, punctiform extravasations. Occasion- 
ally, a fibrinous exudate (" pseudomembrane ") was seen. 
The swelling was less marked than is usual in middle-ear 
suppurations. Bezold never found the mucous membrane 
destroyed so as to expose the bone. The tympanic mem- 
brane in all the cases described showed a marked resistance 
to the attacks of the disease, being thickened, but otherwise 
intact, even in those cases which came to the autopsy as 
late as the thirty-third day after the appearance of the erup- 
tion. We could not expect, therefore, to have any appre- 
ciable changes in the otoscopic image at this stage of the 
disease, and as it does not give rise to any marked subjec- 
tive symptoms, it is probable that such low grades of inflam- 
mation pass off without being observed clinically. The 
prognosis is good ; after the inflammation subsides and the 
exudate is absorbed the parts are completely restored to 
their normal condition. 

It is not to be inferred, however, that all aural complica- 
tion in measles run this benign course. We know from 
practical experience that acute purulent otitis media ivith 
perforation is a very common sequel of measles, and, if 
neglected and allowed to become chronic, it may lead to 
any of the consequences — such as caries of the bone, ex- 
uberant granulations, and cholesteatomata — which we are 
accustomed to see after any suppurative process in the 
middle ear. To show how wide-spread is the belief among 
the laity that measles may be followed by disease of the 
ear, it may be mentioned that in about 3 ^ ^ of all cases of 
aural disease measles is given as the original cause by the 
patient or his friends, and that 5.1 ^ of all cases of purulent 
otitis media are attributed to this disease. Again, that 

1 From Blau and Bihkner. 



the otitis of measles is not quite so benign as might be sup- 
posed from the shght attention it has received even in medi- 
cal circles, — there being a general impression that it requires 
no special treatment, — is shown by the fact that measles is 
charged with 4^ of all cases of acquired deaf-mutism. As 
has been previously indicated, the otitis that accompanies 
measles is not especially malignant, and runs much the 
same course as any other acute or chronic otitis media. 
Blau succeeded in curing 28 cases of acute purulent otitis 
following measles without the hearing being impaired. 
Bone disease with abscess formation is not more common 
after measles than in ordinary otitis media. 

Otitis usually makes its appearance during the stage of 
desquamation between the second and third week ; two 
cases have been reported in which it appeared before the 
eruption. 

The course of the disease presents nothing characteristic. 
Blau 1 reports a case of diphtheric disease of the external 
auditory meatus, without involvement of the middle ear, 
which appeared five days before diphtheria of the pharynx 
following measles. Haug ^ describes a primary caries of 
the mastoid process, with secondary suppuration of the 
middle ear, which developed during the stage of desqua- 
mation. We do not attach much importance to Moos's ^ 
observations that disease of the internal ear with sudden 
deafness and vertigo may follow an attack of measles, as 
they lack the confirmation of other observers. 

A review of our knowledge concerning the nature and 
course of the otitis of measles justifies the following con- 
clusions : It appears, from the results of clinical and ana- 
tomic investigations, that there are two varieties of otitis in 
measles, the second of which represents a complication of 
the first. The otitis media described by Bezold and others 
represents a true measle eruption affecting the mucous 
membranes, while the suppurative process with perforation 
of the tympanic membrane must be regarded, after Bezold, 
as the result of a mixed infection which finds a favorable 
soil in the mucous membrane weakened in its resisting 
power by the primary disease. 

Another view, which is advocated by Wagenhauser * and 

1 " Berlin, klin. Wochen.," vol. XXXIII, 1SS4. 

2" Arch. f. Ohr.," xxxii. p. 1S3. ^ i< Zeitschr. f. Ohr.," XVIII. 

* Quoted by Habermann, " Schwartze's Ilandb.," I, p. 761. 



112 ACUTE INFECTIOUS DISEASES. 

others, regards the otitis of measles as a simple inflamma- 
tion derived from the postnasal space through the Eusta- 
chian tubes ; but in the light of recent investigations on 
cadavers, this view seems to us to lack general application, 
although it may hold in isolated cases. The early devel- 
opment of the acute inflammation, coincident with the 
appearance of the eruption, confirms the hypothesis that we 
have to deal with a true measle eruption precisely analo- 
gous to that on the mucous membrane of the respiratory 
tract, and worthy of a place in the general symptom-com- 
plex in measles. We know from the investigations of 
Bezold that the catarrhal process in the middle ear runs a 
very chronic course, and that the mucous membrane shows 
little tendency to regeneration and granulation ; hence, its 
susceptibility to secondary infection, even several weeks 
after the measles has run its course, is quite readily under- 
stood. 

2. SCARLATINA, 

Among the complications of scarlet fever in the upper 
air-passages we distinguish catarrhal angina and a form of 
diphtheria. 

The catarrh of scarlet fever is distinguished from that 
which occurs in measles by being restricted in the main to 
the pharynx, faucial pillars, and tonsils, while the nose and 
larynx usually escape, or, at any rate, become involved 
much later. It manifests itself as a deep-red or violaceous 
discoloration, at first uniform, and after a few days dis- 
tributed in patches ; the mucous membrane is dry and very 
much swollen, causing a feeling of dryness and tickling in 
the throat and a desire to swallow at frequent intervals. 
The onset and course of the angina do not appear to follow 
any definite rule ; in most cases it appears before the erup- 
tion and lasts several days. 

In some cases of malignant scarlatina without eruption, 
which terminate fatally very soon after the onset of the dis- 
ease, with grave constitutional symptoms, this dark-red dis- 
coloration of the pharyngeal structures may form the only 
symptom, and its relation to scarlet fever can be determined 
only by the existence of an epidemic or by the subsequent 
outbreak of the disease in other members of the family. 

The regularity with which this catarrh of the mucous 



MEASLES. 113 

membrane appears at the very outset of the infectious dis- 
ease, and its locahzation in the region of the pharyngeal 
ring, so abundantly supplied with lymphatic elements, jus- 
tify the assumption that the virus of the disease, the nature 
of which is not known, gains entrance to the system at 
this point, and that the angina of scarlet fever represents 
the earliest reaction of the organism to the scarlatinal 
poison. 

In uncomplicated cases these catarrhal symptoms subside 
in a few days, but in a large proportion of cases a strepto- 
coccal infection of the diseased mucous membranes is super- 
added to the scarlatinal poison and gives rise to a group of 
morbid phenomena which are designated by the general 
term " diphtheroid scarlatina." It is a necrotic inflammation 
of the mucous membrane, presenting the anatomic picture 
of diphtheria, but having etiologically nothing in common 
with genuine diphtheria, from which it is distinguished by 
the absence of Loffler's bacilli and by certain clinical differ- 
ences in the mode of spread and the development of 
sequels. 

Before Heubner's publications appeared to throw some 
light on the question, the greatest confusion prevailed in 
the diagnosis and description of diphtheroid scarlatina, the 
shadow of which overhangs even the most recent rhino- 
otologic literature and materially detracts from the value of 
reported observations. 

Heubner ^ divides diphtheroid scarlatina into three forms, 
according to the clinical course, — a mild form, a subacute 
form, and an epidemic form, — which together represent 
various grades of virulence, both in respect to the extent 
of mucous membrane involved and to the manner in which 
the neighboring glands react to the poison. ' The first form 
is characterized by the deposition on the first to the third 
day of small superficial exudates on the surface of the 
inflamed tonsils ; these soon run together and form a deli- 
cate membrane, which can be removed with a pair of for- 
ceps without causing hemorrhage. After persisting a few 
days the membrane is replaced by shallow ulcers which 
rapidly heal, while the swelling of the submaxillary glands 
subsides. 

Heubner observed this favorable course in about one- 

i"Volkmann's Vortr.," No. 322 (iSSS); and Hirschfeld, " Jahrb. f. 
Kinderheilk.," vol. XLiv, p. 237. 
8 



114 ACUTE INFECTIOUS DISEASES. 

fourth of all cases of scarlatinoid diphtheria. In almost all 
cases the mild form is followed by the so-called subacute 
['' Icntcscoit" ) form of scarlatinoid diphtheria (Hirschfeld 
observed it in 53.6^ in a series of 211 cases); or the 
milder form may not be present and the subacute may be 
the first to appear. After a mild onset the temperature rises 
suddenly on the fourth or fifth day, the glands become 
enlarged, and a yellowish exudate appears on the tonsils, 
on the posterior pharyngeal wall, and on the pillars of the 
fauces. The diphtheric process spreads to the postnasal 
space, the nasal cavities, and the larynx, and gives rise to 
ulceration and tissue destruction varying in form and extent. 
This purulent form of rhinitis is always the result of exten- 
sion from the postnasal space, and therefore develops a few 
days later ; the clinical picture presents no characteristic 
features to distinguish it from diphtheric disease of the nose. 
There is, however, a characteristic discharge of a thin, yellow- 
ish, offensive fluid, tinged with blood, from the excoriated 
nares, which, in connection with the glandular enlargement, 
is of some value for early diagnosis. It is a sign that the 
nasopharynx is involved, and appears even before the nose 
itself is directly attacked. 

It is somewhat remarkable that the larynx is rarely in- 
volved in this form of the disease, just as in the catarrhal 
variety, so that a laryngeal stenosis simulating true diph- 
theria is a rare occurrence. If the membrane does spread 
to the larynx, it is found to be soft and semifluid, and 
much less adherent than in diphtheria. In rare cases 
edema of the larynx and asphyxia were observed ; Moure 
saw an abscess at the base of the epiglottis and about the 
upper part of the left ventricular band which ruptured 
spontaneously on the tenth day of scarlet fever. 

The loss of substance caused by the destruction of large 
tracts of mucous membrane in the postnasal space and on 
the pillars eventually leads to the formation of permanent 
scars and cicatricial contractions, which in later life may 
easily be mistaken for syphilitic scars, especially when they 
occupy the interv^al between the pillars of the fauces and 
the posterior pharyngeal wall. The formation of adhesions 
in the interior of the nose in scarlet fever should also be 
mentioned ; the skeleton itself is never involved. 

Finally, Heubner describes a vialignaiit form which pre- 
sents all the symptoms of an intense general septicemia, 



] 



SCARLET FEVER. I I 5 

with rapid destruction of the mucous membrane of the nose 
and throat, and with necrosis of the cervical and parotid 
glands and of the skin covering them ; the glands at first 
are of a stony hardness. This variety, which appeared in 
16.3^ of the 211 cases in Heubner's clinic, terminated 
fatally about the seventh to the tenth day. 

Diphtheric disease due to scarlet fever presents certain 
important distinctions from true diphtheria, caused by 
Loffler's bacillus, in the nature of the sequels which are 
apt to follow. The peripheral palsies which constitute 
some of the most dreaded after-effects of diphtheria, and 
of which we are concerned only with paralysis of the pillars 
of the fauces and of the larynx, are never observed after 
scarlet fever. This is confirmed by Heubner and by Leich- 
tenstern, who refers to 600 cases, so that the isolated con- 
tradictory cases, cited for the most part by, older writers, 
must be explained in some other way. Without giving 
the individual case histories, Wreden 1 makes the statement 
that he observed paralysis of the pillars of the fauces, the 
vocal cords, the extremities, and the heart in eighteen cases 
of nasal and pharyngeal diphtheria complicated with scar- 
latina. But, in the first place, any ulceration in the pillars 
of the fauces may interfere mechanically with the move- 
ments of the uvula ; and, in the second place, there have 
been reported cases of genuine diphtheria combined with 
scarlet fever when the finding of Loffler's bacillus rendered 
the diagnosis absolutely certain (Jurgensen^). In such 
cases of double infection the occurrence of post diphtheric 
palsies is, of course, conceivable, but they must be attrib- 
uted to the diphtheria and not to the scarlet fever. 

Scarlet fever plays a more important role in the etiology 
of diseases of the ear than any of the other infectious dis- 
eases. The literature does not afford many statistics in 
regard to the frequency of aural disease as a complication 
of scarlatina, the only statistics I was able to find being 
those of Burckhardt-Merian, who reports middle ear dis- 
ease in 5 out of 15, and in another series in 8 out of 36, 
cases. On the other hand, the frequency of scarlatina as 
the original cause of aural diseases forms the subject of 
numerous articles based on a large amount of material. 
The most reliable statistics are those contributed by 

1 Wreden, " jNIon. f. Ohr.," Ii, p. 151. 

2 Nothnagel's "Spec. Path. u. Ther.," IV, 2, p. 133. 



Il6 ACUTE INFECTIOUS DISEASES. 

Bezold/ who collected 640 cases of aural disease second- 
ary to scarlet fever, covering a period of eleven years, 
from 1 88 1 to 1892, in which 984 organs of hearing were 
affected, one-half of all the cases being bilateral. The total 
number of cases of scarlet fever during the same period 
Bezold estimated from other statistical sources at 17,087, 
so that 3.75 ^ of all aural affections must be attributed to 
scarlet fever. This percentage tallies approximately with 
the results of other statistics, ^ in which the percentage 
ranges from 2.3 to 9.3, with a total average of 5.17 ^. 
The frequency with which the different parts of the ear are 
affected varies greatly, affections of the middle ear showing 
a heavy preponderance over those of the internal, and espe- 
cially of the external ear, which are extremely rare. To 
show how frequently the middle ear is involved, it is only 
necessary to state that about 1 2. i ^ ^ of all cases of pu- 
rulent otitis media must be regarded as secondary to scarlet 
fever. 

While these figures alone suffice to show the significance 
of scarlet fever in the etiology of aural diseases, it becomes 
even more apparent w^hen we consider the functional dis- 
turbances and other sequels that follow in its wake. To 
quote at random from Bezold's statistics, we find the appall- 
ing statement that in 109 out of 217 cases of chronic puru- 
lent otitis media with polypi, and in i 54 out of 3 1 5 cases 
without polypi, the disease lasted longer than eight years. 

When it is considered that in 48.5 ^/o of all Bezold's cases 
the distance at which whispered tones could be heard was 
less than ^ of a meter, and that in 13.5/^ a whisper could 
not be heard at all, and when, in addition to this, the fre- 
quency of acquired deafmutism after scarlet fever, which 
shows an average of 19%,"* is taken into account, it is easy 
to understand the otologist's repeated appeals to the gen- 
eral practitioner, adjuring him to devote more attention to 
aural complications in scarlet fever than appears to have 
been done hitherto. 

We will first consider the grave andfortunately rare form 
of otitis which is designated the diphtheric form, being anal- 



1 " Uberschau iiber den gegenwartigen Stand," etc., 1S95, Wiesbaden, 
Bergmann, pp. 168, 169, table viii. 

2 Blau, " Arch. f. Ohr.," 27, p. 140. 

^ Average of Blau's figures, "Arch. f. Ohr.," 27, p. 142, table il. 
4 Blau, loc. cit., p. 143, table iv. 



SCARLET FEVER. I I / 

ogous to diphtheroid scarlatina of the throat. The same 
confusion that prevailed in regard to the diseases of the 
throat before the subject was somewhat clarified by the 
works of Heubner and others still befogs the various de- 
scriptions of diphtheric inflammations of the ears in scarlet 
fever. The opinion is abroad, based chiefly on the writings 
of Wreden and Burckhardt-Merian, that otitis in the course 
of scarlet fever in practically every instance consists in a 
diphtheric inflammation of the middle ear. ~ The i8 cases 
reported by Wreden, which date from the year 1868, can 
not be regarded as authentic, as they represent suppura- 
tions occurring " during the decline of scarlet fever " (sub 
decursu febris scarlatinosae) ; the time of their appearance 
(late in the course of the disease), and the statement that they 
were frequently followed by palsies, arouse the suspicion 
that we have to deal with a genuine complication of scarlet 
fever with diphtheria, and Burckhardt-Merian 's remarks on 
diphtheria, found in his paper on otitis in scarlet fever, are 
of no value in the present discussion, for the very reason 
that the diphtheria of scarlet fever is a very different thing 
from genuine diphtheria. 

From the description ^ ^ by Moos and Pulitzer, who 
designate diseases of the ear in scarlet fever simply as diph- 
theric diseases or scarlatino-diphtheric suppurations of the 
middle ear, it might be inferred that the diphtheric form is 
the only possible aural complication in scarlet fever. But 
how, then, are we to reconcile the frequency of middle ear 
disease in scarlatina with the rarity of diphtheric disease of 
the middle ear? Gottstein's unsuccessful attempt to prove 
that the diphtheric aural affection forms an integral part of 
the morbid process in scarlet fever is followed by the in- 
genious explanation that the aural affections did not come 
under the observation of the ear specialist until after the 
end of the diphtheric and the beginning of the purulent 
stage, while Wreden had the opportunity to observe the 
disease in its early stages. A strange caprice of fate, in- 
deed, if that early diphtheric stage regularly escaped the 
notice of the physician ! 

The most authentic cases of a diphtheric form of otitis 

1 " Schwartze's Handb.," vol. I, " Allgemeine Aetiologie der Ohren- 
krankheiten." 

^ " Lehrb. der Olirenheilkunde." 



I I 8 ACUTE INFECTIOUS DISEASES. 

media in scarlet fever are those reported by Blau,^ Katz,^ 
and Siebenmann.3 

According to these observers, the cHnical course of the 
disease is as follows : Coincident with the diphtheric com- 
plication in the throat there takes place a rapid destruction 
of the tympanic membrane followed by an otorrhea, in 
which the fluid is described as muddy and serous in char- 
acter, not purulent. A diphtheric membrane is formed on 
the mucous membrane of the tympanum and discharged 
into the external meatus. The diphtheric process is not 
limited to the middle ear, and may manifest itself in the 
formation of membranes in the external meatus and in the 
auricle, as was observed in several instances. Blau's case 
was not followed to the end ; the cases reported by Katz 
and Siebenmann terminated fatally on the fifteenth and 
twentieth day respectively. Siebenmann's attempts to dis- 
cover diphtheria bacilli in the membranes found in the 
middle ear after death were unsuccessful. 

As the disease progresses the mucous membrane under- 
goes necrosis ; the bones of the tympanum are laid bare, 
and may eventually become carious. The serous, muddy 
secretion is later replaced by a purulent discharge ; in other 
words, the diphtheric process is converted into a chronic 
suppuration characterized by extensive carious destruction. 
The coincidence of this form of otitis with the diphtheric 
process in the throat suggests the thought that they are 
both caused by the same malign influence manifesting itself 
in different parts of the body. The simplest explanation of 
the aural complication on this tlieory would be direct 
extension of the diphtheric process in the pharynx through 
the Eustachian tube, but of this we have no proof. In 
Siebenmann's case, which is so excellently described, the 
tube was unfortunately destroyed at the autopsy. 

A much more frequent form of aural complication in 
scarlet fever is unite otitis media without any special char- 
acteristic features. It begins during the period of desqua- 
mation, — that is to say, in the third or fourth week of the 
disease, — with a rise in temperature and pain radiating from 
the affected ear and increasing in severity toward evening, 
so that the patient is unable to sleep. There is usually 

1 "Berlin, klin. Wochen.," i8Sl, Nos. 49, 50. 

2 "Berlin, klin. Wochen.," 1S84, No. 13. 

3 " Zeitschr. f. Ohr.," XX, p. I. 



SCARLET FEVER. I I 9 

some glandular enlargement behind and under the angle of 
the jaw, on the mastoid process, or in the back of the neck. 
The tympanic membrane is red, swollen, and inflamed, and 
bulges so that immediate paracentesis is indicated ; if it is 
not performed, spontaneous perforation takes place, often 
within a few hours after the first appearance of subjective 
symptoms. An important variation from the ordinary clini- 
cal picture as just described is to be found in the description 
given by some observers of a remarkable absence of pain, 
which they arbitrarily attribute to anesthesia of the sensory 
nerves. 

Up to this point the course of the disease is essentially 
the same as that of simple otitis media, but after the occur- 
rence of perforation, which preferably takes place in the 
lower anterior quadrant, the membrane undergoes rapid 
disintegration and is often totally destroyed. According to 
Bezold,^ total destruction of the membrane occurs in 
25.2^ of all cases of scarlet fever, and a destruction of at 
least two-thirds of the disc in 24.7^. The flow is very 
abundant and presents the usual mucopurulent appear- 
ance. The most characteristic features of the otitis media 
are an obstinate resistance to treatment and a tendency to 
carious destruction, which frequently involves the ossicles, 
as well as the bony walls of the tympanum and contigu- 
ous cavities. As the hearing is much impaired in scarlet 
fever, it is probable that the disease extends to the internal 
ear ; but whether we have to deal simply with a secondary 
carious destruction of the labyrinth, or with a special locali- 
zation of the disease, is not known. 

How are we to explain the origin of this form of otitis in 
scarlet fever ? 

Is it a disease due to the extension of the initial pharyn- 
gitis through the tubes, and presenting phenomena in the 
form of an otitis media such as we must expect after any 
catarrhal rhinopharyngitis ? or is it a specific disease 
caused by the virus of scarlet fever or by certain toxins 
which it produces ? 

Mere hypotheses add little to our knowledge, which 
must necessarily remain incomplete as long as the nature 
of the scarlatinal contagium is unknown. Certain con- 
clusions can, however, be drawn as to the origin of the 

1 Loc. ciL, p. 172. 



I20 ACUTE INFECTIOUS DISEASES. 

disease from the time of its appearance as a complication 
and from its general character. It occurs regularly during 
the period of desquamation — at a time, therefore, when 
there exists a tendency to other complications as well ; 
for, except in the rare cases of diphtheroid scarlatina, there 
is no record of its occurring immediately subsequent to the 
scarlatinal angina which lasts only a few days. That the 
resisting power of the mucous membrane of the tubes and 
of the tympanum to the invasion of pathogenic germs — 
which might set up a suppurative process in the middle 
ear independent of the scarlatina — is especially lowered 
during this period of the disease is not only not proved, 
but is even improbable, as no such condition of affairs is 
observed in the mucous membranes of the upper air- 
passages, where secondary streptococcal infections usually 
follow immediately after the scarlatinal angina, in the first 
week of the disease. 

Again, if we assume that the aural complication is 
merely accidental, or that it is dependent on the pharyngeal 
condition, it is, to say the least, remarkable that simple 
catarrh and mild otitis media without perforation do not occur 
in scarlet fever, or at least are so rare that they can not be 
included among the list of compHcations of the disease. 

If, on the other hand, we consider that it is during the 
desquamation period that we find nephritis, — a disease 
which is unquestionably toxic in character and there- 
fore indicates a septic condition of the organism, — the 
assumption that the aural complication is due to the action 
of the same toxins seems plausible. If a parallel could 
be established between nephritis and purulent otitis media, 
— as in a case observed by Voss, where the onset, course, 
and subsidence of the two diseases progressed pari passu, — 
it would offer another argument in support of the dependence 
of the aural disease on a general intoxication of the system. 

The bacteriology of scarlatinal otitis media and the sig- 
nificance of a mixed infection have not as yet been dis- 
cov^ered. 



3. VARICELLA. 

In varicella, vesicles appear on the mucous membrane of 
the mouth and pharynx at the same time as the skin erup- 
tion ; in rare cases a few isolated pustules were found in 



VARICELLA. VARIOLA. I 2 I 

the larynx. Cases of grave suffocative laryngitis have 
been described by Marfan and Halle ^ and by Harlez,^ 
which, it appears, occurred suddenly at the time of the 
eruption, with symptoms of asphyxia, attended with hoarse- 
ness, cough, and muffled phonation. Tracheotomy was 
required in every instance ; no laryngoscopic examinations 
are reported ; in one of the cases ulcers were found on the 
vocal cords at the autopsy. 

In a unique case reported by Biirkner, ^ two pustules 
were found in the external auditory meatus, with only a 
-scanty eruption on the scalp. 



4. VARIOLA. 

In variola the mucous membranes contiguous to the 
external skin are regularly attacked. E. Wagner * found 
that the nasal mucous membrane was affected in every case 
in which it was examined. In a series of 170 cases the 
upper pharynx alone was affected twice ; the pharynx and 
larynx alone, 38 times ; the pharynx, larynx, and upper 
half of the trachea, 54 times ; the pharynx, larynx, trachea, 
and large bronchi, 52 times. The larynx was therefore 
involved altogether in 144 cases out of the 170. Between 
the third and sixth day of the smallpox eruption (Macken- 
zie) pustules make their appearance in the pharynx and 
spread to the postnasal space and larynx. They may 
be isolated in different parts of the larynx, or they may 
be multiple and coalesce to form large ulcers. At first 
the pustules resemble those on the external skin, but the 
covering of mucous membrane soon becomes macerated, 
is cast off, and leaves a red, excoriated patch, which is apt 
to bleed. In the hemorrhagic form ecchymoses appear in 
the mucous membranes. These superficial eruptions on 
the mucous membranes are complicated with deeper ulcer- 
ative processes, which lead to edema of the larynx and 
abscess formation ; by extension to the cartilages this may 
give rise to a perichondritis of the larynx, as illustrated by 

1 " Rev. d. mal. d. 1' enf," Xiv, Jan., 1S96, rep. in " Semon's Centralb.," 
xn, p. 499. 

2 " Indep. med.," July 14, 1S97, rep. in "Semon's Centralb. ," xn', p. 
214. 

^"Arcli. f. Ohr.," 18, p. 300. ^"Arcli.d. Ileilkunde," xni. 



122 ACUTE INFECTIOUS DISEASES. 

Tiirck ^ in a number of cases. In addition to the pustular, 
Mackenzie mentions a papular form, and Lori reports 
hyperemia of the mucous membranes without pustular 
eruption. 

Ruhle,2 among others, speaks of a diphtheric croupous 
inflammation of the laryngeal mucous membrane, with 
secondar}^ invasion of the postnasal space. That this was 
the result of confluence of the pustules is denied by Lori 
on the ground that there never were any pustules on the 
mucous membrane ; but E. Wagner says that in the nu- 
merous cadavers he examined the pustules were often so 
closely set, especially in advanced stages of the disease, 
that it was difficult to demonstrate their variolous character. 
Finally, we have the occurrence of palsies as a very rare 
complication. Mackenzie saw two cases which were fol- 
lowed by paralysis of the adductors of one cord. The 
nature of these palsies is not known, but they are probably 
due to mechanical causes, such as ankylosis of the ary- 
tenoid cartilage, observed after perichondritis or after 
the cicatrization of a deep ulcer. 

Aural disease during smallpox was studied by Wendt^ 
in 1 68 organs taken from 84 persons of all ages who had 
died in various stages of the disease. As the ears were 
found to be intact in only 3 cases, there can be no doubt 
of the frequency of aural complications in variola. The 
nature of the lesions varies, according to Wendt's findings ; 
in some instances the morbid process was identical with, or 
closely related to, variola, in others the lesions were such 
as occur in connection with other constitutional or local 
diseases, or even without them. From the external skin 
the eruption spreads to the concha and auditory meatus ; 
from the mucous membrane of the pharynx to the pharyn- 
geal orifice of the tubes. Whether the epithelial thicken- 
ing and suppuration, and the hyperemias, hemorrhages, 
and exudations in the middle ear, are the product of the 
primary disease or the result of the tubal condition is an 
open question. 

So far as has been observed, the tympanic membrane 
is never the seat of a pustular eruption, but it is frequently 
found to be red and swollen. These anatomic findings 

1 " Klinik der Kehlkopf krankheiten." 

2 "Klinik der Kehlkopf krankheiten," lS6l. 

3 "Arch. f. Heilkunde," xni. 



TYPHOID FEVER. I 23 

of Wendt are directly contradicted by the clinical observa- 
tions ofOgston.i The latter, after examining the ears of 
229 smallpox patients, reached the conviction that "the 
structures and tissues of the ear itself are not affected by 
variola." 

The prognosis, according to Wendt, is favorable ; he be- 
lieves that the healing of the smallpox lesions in the ear is 
not followed by any functional disturbance, nor have there 
ever been found cicatricial stenoses or synechise from the 
healing of pustules in the external auditory meatus or in 
the tubes. 



5. TYPHOID FEVER. 

The laryngeal phenomena occurring in the course of 
typhoid fever may be divided into three main groups — 
catarrhal conditions, ulcerations, and palsies ; edema and 
perichondritis are regarded as accompaniments or com- 
plications of one of the three main divisions. There are 
plenty of data to determine the frequency of these compli- 
cations, but a certain reserve is necessary in drawing 
general conclusions, for the statistics would be quite differ- 
ent if a systematic laryngoscopic examination were made in 
every case of typhoid fever, without waiting for the patient 
to complain of pain in the throat or for the appearance of 
such obvious symptoms as dyspnea and aphonia. The 
results obtained vary according as they are based on ob- 
servations made on the living subject or on the cadaver, 
for complications are naturally much more frequent in 
severe cases of typhoid terminating fatally than in the 
milder forms. Another factor is the severity of the epi- 
demic that happens to furnish the basis for the statistics. 
The most comprehensive figures are those published by 
Luning,^ who puts the percentage, as computed from 
clinical statistics, at 3, and the postmortem percentage at 17. 

It would be interesting to know the relative frequency 
of the various forms of laryngeal disease ; but on this point 
we can not hope for any information from the results ob- 
tained at autopsies, as they naturally include only the 
gravest complications, such as perichondritis or diphtheric 
disease. 

1 "Arch f. Ohr.," vr, p. 267. 2 " Langenheck's Arch.," vol. xxx. 



124 ACUTE INFECTIOUS DISEASES. 

Clinically speaking, simple catarrh and superficial ulcera- 
tion are the complications most frequently observed, while 
deep ulcerations which lead to edema and perichondritis, 
or which, when extensive, present the so-called diphtheric 
form (" laryngotyphus ") are much rarer. If the latter are 
more frequently and more fully described it is only because 
of their alarming symptoms and the laryngeal stenosis 
which characterizes them and directly threatens the patient's 
life. Stenosis and edema of the larynx are sometimes 
induced by typhoid processes in neighboring organs ; thus, 
cases have been reported in which acute inflammation or 
abscess formation in the thyroid gland — which condition 
appears to be quite frequent in the course of typhoid — led 
to compression of the trachea and edema of the larynx. 
Our knowledge of post-typhoidal palsies is of very recent 
date. They were formerly considered a very rare com- 
plication, for Lublinski could collect no more than 25 cases, 
including 6 of his own, and Landgraf met with only 2 
cases of laryngeal palsies among 166 typhoid patients. A 
special interest, therefore, attaches to Przedborski's^ report, 
accompanied by very complete case histories, of 25 laryn- 
geal palsies among 100 cases of abdominal typhoid, and 
of 7 among 25 cases of exanthematous typhoid. 

The pharyngeal and laryngeal mucous membrane is often 
attacked by catarrh in the beginning of the disease, while, 
on the other hand, the nasal mucous membrane not only 
escapes but presents an unusually dr}^ appearance. The 
only nasal symptom observed is epistaxis. The hemor- 
rhage shows a predilection for the septum, but is also ob- 
served in other parts of the mucous membrane. In a few 
cases which came under my observation the nasal mucous 
membrane after the hemorrhage presented the previously 
mentioned desiccated appearance, the septum was marked 
with rhagades, while the walls and interior of the nose 
were covered with larger and smaller masses of black, 
clotted blood, which moved to and fro with the respiratory 
movements. The epistaxis occurs in the beginning of the 
disease. As the patients at this time are usually in bed 
and more or less prostrated by the fever, the blood usu- 
ally flows backward into the throat, and the resulting bloody 
sputum may give rise to errors in diagnosis. Perforation of 

1 Volkmann's " Sammlung klin. Vortr.,'" Xo. 182, 1897. 



TYPHOID FEVER. 125 

the septum, like that produced by a perforating ulcer, has 
been observed after typhoid fever. Typhoid pharyngitis and 
laryngitis are characterized by intense redness, while the 
swelling of the mucovis membrane is comparatively slight. 
Marked swelling and edema are rare in this stage. The 
so-called catarrhal redness of the larynx in typhoid is 
not uniformly distributed. It may be due to venous stasis 
(Landgrafi). 

Ulcers appear in various forms both clinically and ana- 
tomically. The commonest variety consists in superficial 
ulcerations from necrosis of circumscribed portions of the 
swollen mucous membrane. They manifest a preference 
for certain regions of the pharnyx and larynx, being found 
almost regularly on the faucial pillars, the free border or 
laryngeal surface of the epiglottis, the aryepiglottic folds, 
and occasionally below the glottis ; they are rarely seen on 
the vocal cords. At first there is a diffuse catarrh, and the 
mucous membrane is darker in color and slightly swollen in 
the areas mentioned ; the epithelium soon breaks down, 
and exposes a small, shallow ulcer with a yellowish floor, 
resembling herpes ; similar ulcers appear in the neigh- 
borhood and coalesce with the original one to form larger, 
irregular, quite superficial ulcers, with clearly defined 
edges, but without redness or swelling of the adjacent 
parts. These ulcers occur in all stages of typhoid, and 
may be due to a variety of causes. They can not be re- 
garded as decubital ulcers,^ as there is no reason why, 
if we accept such an etiology, similar ulcers should not 
occur in any other disease attended with the same degree 
of prostration ; nor can they be attributed to the effect of 
contact and direct infection with the typhoid bacillus, as it 
has been possible in only a very few instances to demon- 
strate the presence of bacilli in the secretion, and there 
is no satisfactory explanation of the mode of infection. 

The ulcers are undoubtedly to be regarded as the result 
of a nutritive disturbance in the catarrhal mucous mem- 
brane connected with the general typhoidal infection, but 
their mode of origin and direct dependence on infection 
by the bacillus are not so clear. They are superficial, and, 
on the whole, may be considered benign, as they heal 
without leaving a scar and do not require any local treat- 

1 Landgraf, "Charite Ann.." 1S89. 

2 Riihle, " VerhdI. der Naturf. Vers.," 1S62. 



126 ACUTE INFECTIOUS DISEASES. 

ment. There are cases, however, in which the ulcers 
extend to the deeper structures, probably as the result of a 
mixed infection. Eppinger^ calls them mycotic necrotic 
ulcers, and gives a detailed description of the way in which 
they invade the deeper structures and eventually destroy 
the perichondrium and cartilage. The cases which go on 
to phlegmon formation are to be explained as due to such 
mixed infection ; Villecourt^ describes one that was local- 
ized in the glottis and posterior laryngeal wall. These 
ulcers differ both clinically and anatomically from the altera- 
tions described by Eppinger under the name of diffuse 
typhoid infiltrations ; he considers them in every way 
analogous to the typhoid lesion in the intestinal follicles, 
and therefore assumes that they originate in circumscribed 
areas containing adenoid tissue in the mucous membranes 
of the upper air-passages. 

These infiltrations lead to ulceration, the ulcers being 
distinguished from those of the first group by the hardness 
and swelling of their undermined edges. Although they 
show no tendency to invade deeper structures, they may, 
as the result of a mixed infection, assume larger propor- 
tions and lead to diseases of the cartilaginous structure of 
the larynx. 

There is one form of diphtheria accompanying typhoid 
often described by older authors (Landgraf also mentions 
a case of typhoid which was probably complicated with 
true diphtheria), in w^hich the disease is said to originate in 
the larynx and pharynx and to extend upward to the 
nasal mucous membrane. As true diphtheric membrane 
corresponding to casts of the interior of the larynx were 
observed, the occurrence of such cases can not well be 
doubted, though they have never been seen by later ob- 
servers, such as Schrotter, for instance. At all events, 
these cases do not represent a true diphtheria, but rather 
the last group of typhoid ulcers, in which, as a result of 
mixed infection, croupous processes develop. 

As in all forms of ulcerations which occasion destruction 
in the deeper tissues, the healing of the ulcers leaves de- 
fects and adhesions, which often lead to stenosis of the 
larynx and may subsequently require local treatment. 
Such sequels may be of various kinds ; their diagnosis 

^ Klebs, " Handb. d. pathol. Anatomic," vol. n, Abth I. 
2 " Gaz. des hop.," 1893, No. 116. 



. TYPHOID FEVER. 12/ 

often presents great difficulties, and they may be con- 
founded Avith syphilitic, diphtheric, and other scars, for 
post-typhoid adhesions present no special characteristics. 
Thus, Halasz^ described a case of membranous adhe- 
sions between the lower edges of the vocal cords after 
typhoid. 

Diseases of the perichondrium and of the cartilages of the 
larynx after typhoid fever deserve special attention. They 
are always to be regarded as secondary, due to the exten- 
sion of the ulcerating process to the perichondrium. They 
present various clinical appearances, and closely correspond 
with diseases of the cartilage from other causes ; a large 
number of very instructive cases, in part illustrated with ex- 
cellent cuts, are found in Tiirck's text-book. The various 
cartilages may become diseased singly or in connection 
with others ; according to a statistical investigation of the 
frequency in the individual cartilages (by Liining, Bus- 
senius, and others), the cricoid cartilage is attacked far 
more frequently than any other. Liining found it affected 
in 44 out of 5 5 cases of perichondritis ; Bussenius2 in 49 
out of 72 cases. This phenomenon is worthy of special 
attention, as Bussenius has shown that the distribution 
of the disease in syphilis and tuberculosis is quite different 
as regards the individual cartilages, the arytenoid cartilage 
being affected in by far the greater number of cases. 

A few cases of paralysis of the laryngeal muscles have 
been observed. They occur chiefly in the stage of con- 
valescence (Mendel, Boulay), but may also be met with, 
according to Przedborski, in the febrile stage. The latter 
is, in fact, said to be the rule in typhus exanthematosus 
(petechial typhus). The paralysis presents no character- 
istic type, and all the muscles may be affected, either singly 
or combined ; Mendel and Boulay found paralysis of 
the adductors in only 4 out of 17 cases. The abductors 
must be regarded as most frequently affected by paralysis, 
but Przedborski, in his 32 observations, reached a different 
conclusion, finding both abductors and adductors affected 
with about equal frequency. But as the former include 
a number of paralyses of the vocal cords, such as we 
frequently observe in anemic persons after exhaustive infec- 

1 " Pest. med. chir. Presse," 1S93, No. 40 ; see " Centralb. f. klin Med.," 
1893, No. 52. 

2 " Charite Ann.," 1S96. 



128 ACUTE INFECTIOUS DISEASES. 

tious diseases, and are therefore in no sense peculiar to 
typhoid, it is quite possible that the figures may have to 
be again revised. It would be interesting to investigate 
the fact reported by Przedborski that the muscles become 
affected one after the other without any definite order such 
as is usually observed in the dev^elopment of a recurrent 
paralysis. Opinions are divided as to the nature of the 
paralysis, but the general tendency is to regard it as anal- 
ogous to that which occurs in diphtheria ; in other words, 
as a peripheral paralysis, such as is observed in other 
infectious diseases, although it is still a matter of dispute 
whether the muscles themselves or the peripheral nerves 
suffer a pathologic alteration. The attempt has also been 
made to explain it as a central paralysis due to hemorrhage 
in the central organs. According to Przedborski, the 
prognosis as to recovery is favorable, as he found that 
the paralysis usually disappeared in the course of from 
one to three Aveeks. 

In a few cases a simultaneous paralysis of one-half of the 
uvula was observed — paralysis pharyngoglossolabialis ; as, 
for instance, in one case of a boy twelve years old.^ 

The ear frequently becomes involved in typhoid, the 
complications being more frequent in typhus exanthematosus 
(petechial typhus) than in typhus abdominalis. We possess 
a few statistics concerning their frequency, based on a 
number of examinations which were made on a series of 
typhoid patients without regard to the presence of any sub- 
jective symptoms. Bezold ^ found fifty aural complications 
among 1243 cases of typhoid (4.02 %); Hengst,^ 28 
among 1228 (2.3 ^); Botkin * saw 19 cases of purulent 
otitis among 357 typhoid patients. The statistics of Zaufal, 
Kramer, and Schmalz, quoted by Biirkner, yield a percent- 
age which varies from 1.8 to 2.5. These figures do not, as 
Haug seems to imply, relate to the frequency of otitis in 
typhoid fever, but to the frequency with which typhoid 
fever was given as the cause of aural disease. The com- 
plications consist mainly in disease of the middle ear ; a 
few isolated cases have also been reported of involvement 
of the external and internal ear, but of this we know very 

^ Briick, *' Sest. raed. chir. Presse," 1891, No. 30; see " Semon's Cen- 
tralbl.," vni, p. 510. 

2 "Arch. f. Ohr ," XXI. ^ u Zeitschr. f. Ohr.," XXIX. p. 184. 

4 See " Mon. f. Ohr.," 1895, p. 135. 



TYPHOID FEVER. 1 29 

little. We will first discuss the middle ear diseases in 
typhoid. Among the 50 cases observed by Bezold, the 
middle ear complication in 48 consisted of inflammation, 
while in only 2 cases was there a simple tubular catarrh 
which was not dependent on the typhoid fever. The in- 
flammatory phenomena usually appear in the fourth or fifth 
week of the disease (according to Bezold, 45 times between 
the twenty-fourth and twenty-fifth day, and only 5 times 
before the twentieth day) ; they are heralded by rises in 
the temperature, which can be referred to the typhoid dis- 
ease, although they occur in the stage of recrudescence, in 
which the fever shows a remittent type with occasional 
marked exacerbations. The patients usually complain of 
earache and tinnitus aurium, and the attendants note a 
diminution in their power of hearing. 

The course of the otitis media is variable, and three forms 
may be distinguished : a simple inflammatory form without 
perforation, a purulent form with perforation of the ear- 
drum, and a form in which involvement of the mastoid 
process is the prominent feature. 

In the first form the otoscopic picture shows moderate 
redness of the ear-drum, especially in the region of the 
handle of the malleus, without any bulging of the mem- 
brane. According to Bezold, the congestion evinces a 
marked tendency to spread to the external meatus. The 
ear-drum shows little or no bulging, and, as a rule, is not 
swollen. This form, which is the mildest, may pass into 
the purulent perforative variety, or the inflammation is so 
acute from the outset that the ear-drum, which shows a 
marked redness, soon bulges outward, and perforation 
rapidly takes place. The suppuration itself is not char- 
acteristic ; perforation is said to occur preferably in the 
posterior inferior quadrant. The size of the opening 
varies, and cases of multiple perforation have even been 
reported. I myself once observed a case in which bilateral 
chronic suppuration, which had existed before the onset of 
the typhoid disease, became arrested during the fever. In 
the fourth week earache made its appearance. The ear- 
drums on both sides were very red, and on the left side 
there was a defect, but no discharge, while the fever still 
continued high. Eight days later, after thefever had fallen, 
the congestion subsided, and marked suppuration again set 
in. These forms of otorrhea which subside during high 
9 



130 ACUTE INFECTIOUS DISEASES. 

temperatures were referred to in the discussion of croupous 
pneumonia, and appear to occur in all infectious fevers 
where the patient is a subject of chronic suppuration. 

One peculiarity of purulent otitis media during typhoid, 
which is mentioned by most authors, is the early involve- 
ment of the mastoid process. Inflammatory phenomena 
make their appearance in the mastoid process at the same 
time that the acute inflammation invades the middle ear, 
and various cases have been described in which there was 
marked tenderness on pressure out of all proportion to the 
appearance of the ear-drum. Brieger observed a case in the 
eighth week of typhoid in which fluctuation was made out 
over the mastoid process within four days after the first ap- 
pearance of the earache, while the corresponding ear-drum 
was markedly hyperemic and quite flat, and only ruptured on 
the next day, the perforation being very small and followed 
by a slight discharge. An operation was performed a week 
after the onset of the pain, and showed the presence of 
sequestrums in the mastoid process. The case ended 
fatally in five weeks, death being due to thrombosis of a 
sinus. Brieger points out that this does not correspond to the 
ordinary course of bone disease following typhoid, as there 
is usually a tendency to spontaneous cure of the inflamma- 
tion. There is no doubt that the bone is extensively in- 
volved. This is shown by Bezold's investigations ; in 19 
out of 41 cases he found marked tenderness on pressure, 
which in 1 1 cases made its appearance at the same time as 
the inflammation. In 5 out of these 19 cases a periosteal 
abscess resulted, and required incision. 

It being established that the bone disease either pro- 
gresses pari passit with the otitis media or precedes it, the 
question of the etiologic relations existing between the 
bone disease and typhoid otitis now presents itself 
According to Bezold, the inflammation in the middle ear 
may begin in one of the three following ways : 

First, by direct extension of the inflammation from the 
nasopharynx through the tube, simple occlusion of the 
tube being probably insufficient to be regarded as an etio- 
logic factor, at least for the suppurative processes. 

Second, by the passage of septic material directly from 
the nasopharynx into the middle ear. 

Third, by the formation of emboli in the vessels of the 
mucous membrane of the middle ear, emanating either 



TYPHOID FEVER. I3I 

from an endocarditis and thrombosis of the left heart, or 
from purulent foci in the periphery, 

Bezold therefore considers the aural complication as 
secondary and excludes the effect of the general infection 
as an etiologic factor. If Bezold's exposition of the eti- 
ology is accepted, it is difficult to explain how the disease, 
which is at first localized in the middle ear, can be trans- 
planted to the walls of the mastoid process with such 
rapidity as to make the secondary, appear to precede the 
primary disease. Even if we admit the possibility of the 
middle ear becoming infected through the tubes, we can 
not discard the theory that we have to deal with an acute 
osteomyehtis of the mastoid process, which is to be re- 
garded as a true complication of the typhoid disease. 
The demonstration of typhoid bacilli would settle the 
matter beyond dispute ; unfortunately, we do not possess 
any bacteriologic data ; however, the course of the bone dis- 
ease, as has been previously stated, is in itself quite different 
from that which is usually observed in the complications 
of typhoid fever, and even if we assume a mixed infection 
to explain the sequestration of the bone and the formation 
of periosteal abscesses, the question why the disease in the 
bone should precede or even accompany the suppuration 
from the ear remains unsolved. 

Complication of the external ear (the auricle and the 
external meatus) is a very rare occurrence. Haug i quotes 
a case of gangrene of the auricles from Obre. Von 
Troltsch and Hoffmann ^ each observed a case of suppura- 
tion of the parotid gland with rupture into the external 
meatus. In Hoffmann's case there was a fistula at the junc- 
tion between the cartilaginous and bony portions of the 
meatus. On the other hand, Botkin ^ observed bilateral 
otitis externa 21 times among 26 typhoid patients, and 
erects the improbable hypothesis that suppurations from 
the middle ear in typhoid are due to an extension of otitis 
externa to the ear-drum and to the tympanic cavity. 

An apparent reduction in the power of hearing is fre- 
quently met with in the course of typhoid fever, although 
no objective changes can be found to account for it. It 
is quite unjustifiable to interpret such cases as nervous 

1 " Die Krankh. des Ohres," etc., p. 90. 

2 " Arch. f. Ohr.," IV, 6th Observation. 

3 See "Mon. f. Ohr.," 1S95, p. 135. 



132 ACUTE INFECTIOUS DISEASES. 

deafness, for clinical experience teaches that the difficult 
hearing is due to somnolence, and improves as soon as the 
mental faculties are restored. I have myself observ^ed that 
the hearing varies during the febrile stage, being remarkably 
improved during the remissions of the temperature which 
follow cold baths. When Haug 1 remarks "that this 
typhoidal deafness sometimes reaches its highest point at 
the crisis of the general disease, and then gradually dimin- 
ishes and allows the ear to return to its normal condition 
during the stage of convalescence," and insists particularly 
on the fact that "disturbances of the sphere of coordination 
have never been observed," we may be pardoned for express- 
ing a doubt of this " nervous ear affection." 

This must not, however, be taken to imply that we deny 
the possibility of the nervous hearing apparatus being in- 
volved in typhoid fever, and there are, in fact, a few obser- 
v^ations which prove that difficult hearing and tinnitus aurium, 
with the other phenomena of the nervous affection, undoubt- 
edly occur during the stage of convalescence ; in fact, the 
anatomic investigations of Pulitzer, Moos, Lucae, and 
Schwartze demonstrated an anatomic basis for this clinical 
picture — a hyperemia of the internal ear or ecchymoses and 
hemorrhages in the vestibule and in the cochlea. The 
clinical cases of nervous deafness which have been described 
as progressive after typhoid fever, must, in the absence of 
detailed histories, be accepted with a reservation, as they 
may have something to do with the exhibition of quinin or 
salicyHc acid during the course of the fever. 



6. INFLUENZA. 

Although the port of entry for the carriers of the infection 
of influenza is probably to be sought in the mucous mem- 
branes of the upper air-passages, the parts themselves are 
directly involved in only a small percentage of the cases. 
Leichtenstern 2 has designated this form as catarrhal res- 
piratory influenza, in contradistinction to the gastro-intes- 
tinal form and the purely toxic form with fever and nervous 
phenomena. The frequency of rhinitis is variously given 
at from 25 ^ to 79^, that of laryngitis from 5 ^ to 16 ^ ; 
these figures appear remarkably low in comparison with the 

^ Loc. cit., p. 95. 

2 Nothnagel's spec. *' Path. u. Ther.," vol. iv, I, p. 77. 



INFLUENZA. 1 33 

frequency with which these conditions are observed in 
practice. 

There can not be said to be a typical clinical picture for 
the complications of influenza in the upper air-passages, for 
they manifest themselves under the most various forms. Two 
principal groups are distinguished — one affecting principally 
the mucous membrane, the other the nervous system. With 
regard to affections of the mucous membranes, it has been 
pointed out by Leichtenstern that the inflammation is not 
uniformly distributed over all the mucous membranes, 
and that the deeper portions do not always become affected 
secondarily to the disease in the upper portions, — i. e., the 
nose and the nasopharynx, as is the case in most other con- 
ditions, — but every portion of the respiratory tract is cap- 
able of becoming primarily affected by the morbid process. 

In the nose the inflammation presents the picture of 
an acute rhinitis which is distinguished from an ordinary 
coryza only by the rapidity of its course, the inflammatory 
symptoms and secretion subsiding within a very few days. 
The rhinitis is occasionally accompanied by epistaxis, 
although we find very contradictory statements in regard 
to this symptom. Schmidt and Litten regard epistaxis 
as a very frequent complication, while Tissier,i Leichten- 
stern, and Frankel,^ on the other hand, say that it is 
comparatively rare. We should mention the occurrence 
of acute or, later, chronic suppurations in the accessory 
cavities as one of the complications. Thus, the maxillary 
sinus is frequently the seat of an acute inflammation, 
accompanied with nasal obstruction and facial neuralgia, 
which immediately disappears either spontaneously or 
after the swelling in the mucous membrane has subsided 
and the orifice of the cavity has been exposed. The 
best descriptions of suppurations of the accessory cavities 
are given by Tissier, who claims to have found all the 
various sinuses affected. Ewald^ reports a very malig- 
nant case in which a purulent basal meningitis developed 
after an empyema of the antrum of Highmore had been 
opened ; the meningeal complication at the autopsy was 
accounted for by the finding of a suppuration in the 
ethmoid cells. 

1 " Ann. des mal. de I'oreille," 1S92, p. 425. 

'■' " Semon's Centralbl.," vii, p. 3S. 

3 "Berlin, klin. Wochen.," 1S90, No. 3. 



134 ACUTE INFECTIOUS DISEASES. 

Catarrh of the pharynx and larynx also presents the 
ordinary picture of an acute inflammation, except that 
hemorrhage appears to be a more frequent complication than 
in the nose ; the term laryngitis Jicviorrliagica has been ap- 
plied to this form of the disease. The affected mucous mem- 
branes are frequently the seat of whitish patches, not ele- 
vated above the swollen and reddened mucous membrane. 
They are analogous to similar patches found in acute 
catarrh, and are to be interpreted as a superficial necrosis. 
In a few instances marked edema of the laryngeal mucous 
membrane was observed, which even went on to abscess 
formation, and Rethi described a coexisting perichondritis 
of both plates of the thyroid cartilage. ^ 

As regards nervous diseases, a few cases of anosmia 
and parosmia have been reported, and while paralysis of 
the palatal muscles and of the constrictors of the pharynx 
may occur, by far the most important complication con- 
sists in paralysis of the laryngeal nerves, which must be 
regarded as a typical influenza neuritis such as occurs in 
all parts of the body. Besides rare cases of paralysis 
of the sensory superior laryngeal nerve we meet with 
paralyses of the laryngeal muscles, both of the adductors 
(Onodi saw an isolated paralysis of the cricoarytenoideus 
lateralis, and Rosenberg frequently noticed paralyses of the 
vocal cords) and of the abductors ; they usually make 
their appearance after the acute inflammation has subsided. 
So far as the observations have gone, the abductors appear 
to be more frequently involved than the adductors, and both 
unilateral and bilateral paralysis of the crico-arytenoideus 
posticus has been observed. Seifert^ reports a unique case 
of a right-sided total paralysis of the vagus which he re- 
gards as peripheral in origin. Besides the usual cardiac 
and circulatory symptoms there was paralysis of the right 
recurrent and of the superior laryngeal nerves. 



AURAL COMPLICATIONS IN INFLUENZA. 

Soon after the appearance of the influenza epidemic of 
1 889-1 890 the attention of aural surgeons was directed to 
the frequency of purulent otitis media as a complication of 
influenza, and the numerous observations that have been 

1 "Wien. klin. Wochen," 1894, No. 48. 

2 '« Rev. hebd. de lar., d'ot. et de rhin.," 1896, p. 1537. 



INFLUENZA. I 3 5 

made since then, and that any physician can make for him- 
self even now in the sporadic cases of influenza, justify the 
conclusion that this epidemic infectious disease occupies an 
important place in the etiology of aural complications. It 
was learned by the statistics of Ludwig and Jansen that a 
rapid increase in middle-ear diseases occurred during the 
months of November and December, 1889, and January, 
1890, and this increase was attributed to the epidemic 
which was prevalent at that time. It is important to note 
that the increase did not affect middle-ear diseases in gen- 
eral, but Avas limited exclusively to inflammations of the 
middle ear. Thus, in the Halle Ear Clinic the number 
reached 137 during the months of the epidemic, as against 
41 or 44 during the same months of the preceding years ; 
and, according to Gruber, there were 625 cases from No- 
vember, 1889, to January, 1890, as against 238 and 84 
during the same period of the preceding years. Jansen's 
statistics are most convincing in this respect : they show 
that the percentage of acute inflammations of the middle 
ear, which in the first eleven months of the year 1889 
amounted to from 10^ to ly.yfo, rose to 37^ in Decem- 
ber, 1889, 29^ in January, and 20.6^ in February 1890, 
although there was no appreciable increase in the frequency 
of simple catarrh of the middle ear. The discrepancy can 
not be explained as an ordinary increase in the frequency 
of the disease due to the season of the year, since the com- 
parison with the months of November, December, and Jan- 
uary of the five preceding years shows a percentage ranging 
from 8.1 to 21.5, and in only one winter a percentage as 
high as 25.5. In spite of the increase in this particular 
form of disease the total number of patients was not appre- 
ciably increased, as might have been expected from the 
general prevalence of disease during the epidemic. Leich- 
tenstern's objection, that "the statistics of specialists merely 
show the enormous distribution of the influenza," is quite 
irrelevant. On the contrary, if we examine the statistics of 
specialists, we find that the great frequency of certain ear 
diseases — such as acute inflammation and suppuration of 
the middle ear which are known to follow in the wake of 
other infectious diseases — and their abnormally rapid and 
malignant course during an epidemic of influenza, are not 
merely accidental, but directly dependent on the epidemic. 
With regard to the frequency of aural complications of 



136 ACUTE INFECTIOUS DISEASES. 

influenza in general we possess only general statistics, 
according to which from o. 5 % to 2 ^ of all cases are com- 
plicated with disease of the ear ; but these figures are prob- 
ably below the true percentage, as the milder cases of 
influenza remain only a short time in the hospital, and the 
aural disease therefore appears only as a sequel. 

The otitis in influenza makes its appearance in the form 
of an acute suppuration of the middle ear from a few days 
to several weeks after the beginning of the primary disease. 
As influenza is an infectious disease with a special prefer- 
ence for the upper air-passages, it is probable that a large 
proportion of the aural affections are due to infection from 
the nasopharynx through the tubes, and, as such, appear 
under the form of an ordinary purulent otitis media. There 
is, in addition, another manifestation of influenza which 
possesses a distinct hemorrhagic character, and is by 
many regarded as a pure form of influenza otitis. These 
two varieties can not be accurately distinguished in prac- 
tice, as the typical appearance in the latter form disappears 
after the first k\v days and is replaced by the picture of an 
ordinary otitis media. The finding of the bacillus of 
influenza — which was first positively reported by Scheibe, 
and after him by several other investigators, although never 
with any regularity — is of very little importance, as sooner 
or later in any form of suppuration from the middle ear 
there develops a mixed infection in which other micro- 
organisms may supplant the primary disease germ. 

As regards the clinical course of influenza otitis, it was 
formerly universally believed that hemorrhages were to be 
regarded as a regular symptom of the disease in the acute 
form, in accordance with the first descriptions given by 
Patrzek, Schwabach, Dreyfuss, and Jankau ; Schwartze, 
however, adheres to his opinion that the hemorrhages 
are not observed with any greater frequency than in inflam- 
mations from other causes. We find ecchymoses, var^ang 
from the size of a pinhead to that of a split pea, either single 
or multiple, on the ear-drum and on the walls of the 
external meatus ; or we may have bluish-red extravasations 
of varying extent, sometimes covering the entire ear-drum. 
Korneri speaks of secondary circular hemorrhages which 
he saw through the ear-drum after hypertrophy of the 

1 " Zeitschr. f. Ohr.," xxvii, p. 11. 



INFLUENZA. 1 3/ 

mucous membrane. The hemorrhages often take the form 
of villous or pouch-shaped diverticula in the tympanic 
mucous membrane, due to marked swelling of the mucous 
membrane of the middle ear, and, after perforation, pro- 
lapse through that structure into the external meatus. 
They show a special tendency to recurrence, and frequently 
reform after simple cauterization. Some observers speak 
of perforation taking place in a definite portion of the ear- 
drum, but the statements are so contradictory that it is not 
worth while to repeat them ; isolated involyement of the 
cupola (infundibulum cochleae) in influenza, mentioned 
by Kosegarten and Haug, must be very rare. The dis- 
charges are bloody on the first day, and hemorrhages 
may occur even later without leading to suppuration, 
while in other cases the bloody discharge is replaced by 
serosanguineous fluid, which is eventually followed by 
suppuration. 

The statement that purulent otitis media in influenza is 
more severe than other forms of suppuration from the mid- 
dle ear is based on the frequent implication of the mastoid 
process (according to Jansen, in 57 out of 105 cases, 25 of 
which necessitated trephining). The complication leads to 
suppurations in the bone and to periosteal abscess, which 
are greatly to be dreaded on account of the intensity of the 
process and its rapid extension. According to Komer, 
Eulenstein, and Lemcke, primary myelitis of the mastoid 
process with secondary involvement of the middle ear 
may occur ; but the opposite direction, from the middle ear 
to the mastoid process, is probably to be regarded as the 
regular mode of infection. 

The internal ear is very rarely involved, and the nature 
of the condition is not known. Lannois ^ and Barnick ^ 
described cases of labyrinthine deafness after influenza. 
According to the former, the prognosis as regards restora- 
tion of the hearing is bad ; according to the latter, favorable. 
Gradenigo ^ mentions difficult hearing after influenza, which 
he interprets as a neuritis of the auditory nerve. ^ 

The occurrence of otalgia tympanicais occasionally men- 
tioned, and although the condition can hardly be diagnosed 

1 "Rev. de lar., d'ot. et de rhin.," 1890, No. 17. 

2 "Arch. f. Ohr.," 38, p. 1S3. 3 See " Arch. f. Ohr.," 36, p. 141. 
* Comp. Leyden and Guttmann, "Die Influenzaepidemie," Wiesbaden, 

1892, p. 132; and Ebstein, " D. Arch. f. klin. Med.," vol. LVili, p. 14. 



138 ACUTE INFECTIOUS DISEASES. 

with certainty, it may be accepted as a possible complica- 
tion through the trifacial nerve, in view of the frequency of 
other neuralgic manifestations in influenza. 



7. PAROTITIS EPIDEMICA (MUMPS), 

In this obscure epidemic disease, which belongs to the 
class of infectious diseases, the general infection manifests 
itself in various parts of the body, showing that the typical 
swelling of the parotid gland is only a local expression of 
the general disease. The commonest complication — that 
of orchitis and epididymitis — is as little understood as the 
occasional involvement of the ear. 

The aural complication usually takes the form of laby- 
rinthine deafness, appearing, as a rule, during the first days 
of the disease, along with other symptoms of Meniere's 
complex, and offering an obstinate resistance to every mode 
of treatment, while the accompanying symptoms of vertigo, 
tinnitus aurium, and disturbances of the equilibrium sub- 
side. Like the complications in the sexual organs, those 
in the ear show a predilection for the age of puberty, being 
most frequent between the tenth and twentieth years. 1 
The total number of cases reported is very small. In 1884 
Connor was able to collect 34 cases, and in 1883 Gradenigo 
could report only 38 positive observations of deafness due 
to mumps. One or both ears may be affected, and there 
appears to be no connection with the situation of the pri- 
mary disease if the latter has been unilateral. There have 
even been reported rudimentary cases in which orchitis 
and deafness were present without glandular swelling (Gra- 
denigo's case). As the prognosis is absolutely unfavorable, 
the disease may, if it be bilateral and occurs in early infancy, 
lead to deafmutism, the frequency of which is given as 
0.3^ by Mygind, in the Saxon deaf and dumb statistics, 
and as 0.5^ by American statisticians. 

The otoscopic picture is in every respect negative, and 
there is absolutely no proof that inflammations of the tym- 
panic membrane and exudations in the middle ear have 
anything to do with the disease. Functional test shows 
deafness or marked reduction in the hearing of the internal 

1 Gradenigo, " Schwartze's Handb.," Ii, p. 440, 



ACUTE RHEUMATOID ARTHRITIS. 1 39 

ear, while, according to Moos,i the power of hearing for 
the lower notes and bone conduction may bfe preserved. 

Numerous attempts have been made to explain the deaf- 
ness of infectious parotitis, but they are all more or less 
improbable, and therefore of no interest. 

The subject will be found discussed at length in papers 
by Rossa,2 Moos,^ Haug,^ Gradenigo,^ and Alt.^ 

Pilatti '^ describes a case of parotitis in which tracheotomy 
was required on account of edema of the larynx. 



8. ACUTE RHEUMATOID ARTHRITIS (POLYAR- 
THRITIS RHEUMATICA ACUTA). 

One of the first diseases in which the tonsils were recog- 
nized as the port of entry for a general infection was acute 
articular rheumatism. The importance of angina in the 
etiology of this disease was first pointed out by Lagranere, 
Boeck, Loebl, Mantle, and others, all basing their asser- 
tions on clinical observations. 

But the confusion that still prevails with regard to the 
cause of acute articular rheumatism was not removed by 
the bacteriologic examination of cases of rheumatoid 
angina, for the greatest variety of microorganisms — 
staphylococcus aureus, pyogenic streptococci, streptococ- 
cus citreus, and pneumococci — was found. As this is not 
the place for a detailed theoretic discussion of the relation 
between the angina and rheumatism, — which will be found, 
together with a complete report of all the cases in the 
literature, in the works of Buss,^ Suchannek,^ and Bloch,i ^ 
— I shall merely refer briefly to the clinical observations 
that have been reported. Any one of the varieties of 
tonsillitis, both catarrhal and follicular, may appear either 
as a forerunner of rheumatism before the joints are 
affected, or as a feature of the fully developed clinical 
picture. The complication can not at the present time 

1 " Berlin, klin. Wochen.," 1S84, No. 3. 

2 " Zeitschr. f. Ohr.," vol. xn. ^ << Schwartze's Handb.," i, p. 584. 
* " Die Krankh. des Ohres," etc., p. 75. 

5 " Schwartze's Handb.," 11, p. 439. 

6 " Mon. f. Ohr.," 1896, p. 525. 

' See " Semon's Centralbl.," Vin, p. 149. 
8 "D. Arch. f. klin. Med.," vol. i.iv. 
^ Bresgen's Sammlung, vol. i, II. i. 
10 "Munch, med. Wochen:," 1S9S, Nos. 15, 16. 



I40 ACUTE INFECTIOUS DISEASES. 

be regarded as a rare occurrence in Germany, as stated 
by Wagner ^ in 1878, and its frequency shows that it 
is not an accidental coincidence, but that it represents a 
symptom of the general disease. Gerhardt ^ mentions, as 
a strong proof of internal connection between tonsillitis 
and rheumatism, a case of Staffel's,^ in which an attack of 
articular rheumatism rapidly followed a severe inflamma- 
tion of the tonsils, and the articular affection was removed 
only after methodical treatment of the mouth. In addition 
to tonsillitis and pharyngitis, we also have catarrhal lar}'n- 
gitis ; but by far the most important diseases of the larynx, 
from a practical point of view, are those which must be 
regarded as typical rrianifestations of the rheumatic infec- 
tion. They may be divided into two varieties, which have 
been designated respectively as disease of the joints of the 
larynx and as laryngitis acuta rheumatica circumscripta 
(Nodosa). 

The crico-arytenoid articulation is the only one tiiat has 
been known to be involved in an acute articular rheuma- 
tism, although the fact that there is no report of the crico- 
thyroid joint being involved may be due to defective diag- 
nosis, and it seems to me that Meyer's ^ case might easily 
be regarded as one of this kind, since the laryngoscopic 
findings w^ere negative. Rheumatism of the crico-arytenoid 
articulation is usually bilateral, and manifests itself in the 
laryngeal image in redness and swelling of the arj^tenoid 
region and in sluggishness or arrest of the vocal cords, sim- 
ulating paralysis. Besides the aphonia, the subjective symp- 
toms consist in a sensation as of a foreign body, dyspnea, 
and dysphagia, all. of which, according to Meyer's descrip- 
tion, are worse when the patient lies down. An important 
diagnostic point is the tenderness over the crico-arytenoid 
joint or over the thyroid cartilage ; in the latter case the 
symptom possibly points to disease of the cricothyroid 
articulation. The laryngeal complication usually develops 
between the fourth and the twelfth day after the onset of the 
articular rheumatism ; the prognosis is favorable, recovery 
usually occurring in a short time (according to Meyer, in a 
week). Grijnwald ^ mentions a case of " cadaver position " 

^ Wagner, " Ziemssen's Handb.," VII, p. 148. 

2 " Verhdl. des Congr. f. inn. Med.," 1896, p. 180. 

^" Zeitschr. f. prakt. Aerzte," 1896, No. 4. 

4 " Berlin, klin. Wochen.," 1894, No. 16. 

5 "Berlin, klin. Wochen.," 1892, No. 20. 



ACUTE RHEUMATOID ARTHRITIS. I4I 

on the right side after articular rheumatism which was cured 
in two years. The disease usually responds promptly to 
salicylic acid. The reported cases, which are very few in 
number, have been collected by Lacoarret ^ and Sendziak ^ ; 
Archambault's ^ thesis is also well worth reading. 

The second form of rheumatic disease in the larynx is 
described by Uchermann ^ as laryngitis acuta rheumatica 
circumscripta (nodosa), although Goldscheider ^ lays claim 
to priority, as he reported an analogous case in an earlier 
paper. The condition occasionally manifests itself in con- 
nection with erythema nodosum as a "circumscribed red- 
dish or bluish-red, moderately firm infiltration, very sensi- 
tive to the touch," which may attain a considerable size (as 
large as an almond), seated usually in the neighborhood of 
the crico-arytenoid articulation or in the aryepiglottic fold ; 
in the former situation pseudo-ankylosis, with immobility of 
the vocal cord, is likely to result. 

As the inflammation also invades neighboring portions 
of the larynx, and thus leads to edema both in the aryepi- 
glottic folds and on the epiglottis, the symptoms of dyspnea 
and dysphagia may be added. 

The prognosis in this form also is favorable. 

Wolf ^ described two cases of acute inflammation of the 
middle ear in acute articular rheumatism. In the first 
case both ears were affected one after the other ; one 
of the ear-drums ruptured spontaneously ; in the other, par- 
acentesis was required. The rheumatism was very severe, 
and did not appear in the joints until several days later ; 
the suppuration which followed the inflammation was cured 
in four weeks. In the second case the aural disease was 
followed after only nine days by diffuse swellings in the 
joints. From the fact that in both cases the impairment of 
hearing and thickening of the ear-drum were permanent. 
Wolf concludes that articular rheumatism may be the cause 
of sclerotic catarrh in the middle ear. A similar case is 
reported by Meniere.'^ We have no knowledge of disease 
in the joints of the ear ossicles ; the possibility of rheumatism 
in the joint between the malleus and the incus, and between 
the incus and the stapedius, is, however, worth considering. 

1 " Rev. de lar., d'ot. et de rhin.," 1S91, No. II. 

2 " Arch. f. Laryng.," iv, p. 264, and VI, p. 168. ^ TWse de Paris, 1886. 
* "Deutsche med. Wochen.," 1897, p. 749. ^ Ibid., p. 807. 

^ " Arch. f. Ohr.," 41, p. 213. 

' " Rev. mens, de lar., d'ot., et de rhin." 



142 ACUTE INFECTIOUS DISEASES. 

The cases reported by Bloch ^ in which disease of the 
ear is said to have produced an acute articular rheumatism 
do not seem to me sufficiently convincing to justify the 
assumption of a new mode of infection for that disease. . 



9. DIPHTHERIA. 

The description of diphtheria belongs to the domain of 
internal medicine, ^ and the manifestations of the disease in 
the nose, pharynx, and larynx will be found amply discussed 
in the text-books. 

I shall not, therefore, attempt to give a description, as it 
does not belong to the scope of this work, and would, if it 
made any pretensions to thoroughness, occupy too much 
space. Instead, I shall confine myself to a discussion of 
the sequels occurring after diphtheria in the nose, pharynx, 
and larynx, and in the ears. 

In the pharynx and larynx we have post-diphtheric 
palsies of both the sensory and motor nerves, the cause 
of which is now generally conceded to be a peripheral 
neuritis. The time of their appearance is usually given 
as from two to six weeks after the diphtheria. The 
paralysis affects most frequently the uvula. The nature 
of the paralysis is unmistakable, as it can be seen by 
direct inspection, and manifests itself, besides, in the con- 
spicuous symptoms of dysphagia, regurgitation of liquids 
through the nose, and nasal speech. Although this 
form of paralysis has occasionally been observed early, fol- 
lowing immediately upon the pharyngeal disease, it must 
be remembered that a paretic condition of the palatal mus- 
cles may be produced by the diphtheric disease of the 
mucous membrane invading the deeper-lying muscles. 

Anesthesia of the pharyngeal and laryngeal mucous 
membrane is much more rare. It was observed in the 
cases cited by v. Ziemssen ^ and elsewhere. 

Paralysis of the vocal cords has been observed with at 
least sufficient frequency to remove any doubt of its oc- 
currence, and it is difficult to understand what could have 
led Baginsky ^ to say that " he was unable to find among 

1 " Miinch. med. Wochen.," 1898, Nos. 15, 16. 

^ The latest description is by Baginsky, in Nothnagel's " Spec. Path. u. 
Then," 11. Bd., i. Th. 

3 In "v. Ziemssen's Handb.," vol. iv, p. 405. * Loc. cit., p. 215, 



DIPHTHERIA. 1 43 

all the reported cases any description of paralysis of the 
crico-arytenoidei postici due to lesion of the recurrent laryn- 
geal nerves after diphtheria ; he himself had certainly never 
seen it." Von Ziemssen ^ reports two cases of diphtheric 
paralysis of the pharynx, larynx, and extremities. In one 
case the left vocal cord was completely paralyzed in the 
cadaver position, while the right was very sluggish and 
limited in its excursions. 

I once saw a doubtful case in which a unilateral complete 
paralysis of the uvula and vocal cords was associated with 
anesthesia of the mucous membrane and abolition of all 
the reflexes. The paralysis occurred about six weeks 
after a mild case of diphtheria, and after it had lasted seven 
weeks the vocal cord gradually returned to the median 
position and finally completely regained its movabihty. 

ClifFord-Beacher ^ observed a case in which paralysis of 
the adductors followed that of the abductors, while recov- 
ery took place in the inverse order. 

According to Lublinsky, ^ postdiphtheric paralysis of 
the vocal cords is more frequent, and occurs earlier when the 
serum treatment is employed ; in one case he saw it as early 
as the ninth day of the disease. 

The prognosis of postdiphtheric paralysis is favorable. 
In anesthesia and impairment of the reflexes in the upper 
air-passages there is some danger of inspiration pneumonia. 

In addition to these peripheral palsies there have been 
observed paralyses of central origin, probably due to hem- 
orrhage, manifesting themselves under the form of hemi- 
plegia and presenting the symptoms of paralysis of the 
uvula and aphasia. It is not stated whether or not the 
vocal cords were also paralyzed. Edgren ^ gives a review 
of the cases reported in the literature, adding some of his 
own. 

Diseases of the ear in diphtheria may be divided into — 

1. Diphtheric inflammations of the external auditory 
meatus. 

2. Diphtheric inflammations of the tube and of the middle 
ear. 

3. Acute catarrhal and purulent inflammations of the mid- 
dle ear without the formation of membranes. 

1 Loc. cit., p. 215. 2 " Semon's Centralbl.," IX, p. 86. 

8 "Deutsche med. Wochen.," 1S95, No. 26. 
*" Deutsche med. Wochen.," 1893, No. 36. 



144 ACUTE INFECTIOUS DISEASES. 

1. Diphtheria of the external auditory meatus is very 
rarely seen. The only reliable observation of its occur- 
rence in connection with pharyngeal diphtheria is that of 
Treitel, ^ while in the other published cases of croupous 
inflammation of the external meatus, by Wreden, Blau, and 
others, the diagnosis of true diphtheria is not positive, some 
of the cases representing the scarlatinal variety. In Trei- 
tel's case, diphtheric membranes were found in both ears, 
representing a complete cast of the external auditory mea- 
tus. The inflammatory symptoms were very marked, and 
there was extensive swelling over the mastoid process. 
The disease extended to the auricle, but the ear-drum re- 
mained intact. 

A bacteriologic examination was made by Kossel, and 
was negative, although he found rod-shaped organisms 
resembling the diphtheria bacillus ; Treitel attributes the 
negative outcome of the cultures to the sublimate solution 
in which he had preserved the membranes before they were 
examined. 

2. As regards diphtheric disease in the tube and in the 
middle ear, we do not possess any positive investigations 
supported by the bacteriologic demonstration of diphtheria 
bacilli, but we are forced by the result of autopsies and by 
clinical observation to assume the occurrence of such com- 
plications in true diphtheria. 

When we attempt to analyze the reported cases, most of 
which belong to the prebacteriologic period, or else are so 
little to be relied upon as to be quite unworthy of dis- 
cussion, it is often difficult to separate cases of false from 
those of true diphtheria. Wreden ^ and Burkhardt- 
Merian,^ for instance, discuss scarlatinal diphtheria and 
true diphtheria and their complications with croupous 
inflammation of the middle ear without making any dis- 
tinction between them. On the other hand, we find in the 
observations of Wendt,^ Kiipper,^ Moos, and Hirsch ^ the 
necessary materials for a description of diphtheric disease 
of the ear. 

The middle ear may be affected alone or in combination 



1 " Deutsche med. Wochen.," 1S93, p. 13S8, 

2 " Mon. f. Ohr.," vol. 11, p. 148. 

3 Volkmann's " Sammlung klin. Vortr.," I. Reihe, Serie vii. No. 182. 
* " Arch. f. Heilkunde," xi and xni. 

5 "Arch. f. Ohr.," xi, p. 20. « " Zeitschr. f. Ohr.," XIX, p. loi. 



DIPHTHERIA. I45 

with the tube. Diphtheric membranes are found adhering 
to the mucous membrane of the tympanic cavity or cover- 
ing the ossicles or Hning the cells in the bone. In a case 
of acute purulent otitis media after diphtheria, reported by 
Lommel,! beginning membrane formation was found in 
individual mastoid cells. 

The symptoms of the disease are those of any acute 
otitis media, rise of temperature and pain being the most 
prominent ; the pain is aggravated by the fact that the ear- 
drum shows no tendency to spontaneous perforation, so 
that expulsion of the membranes into the external meatus 
occurs only after paracentesis has been performed. 

The course of a croupous disease of the ear following 
diphtheria appears to be the same as that of one following 
scarlet fever ; both diseases are considered equally malig- 
nant as regards destruction of the walls and of the ossicles 
in the middle ear, the production of extensive caries in the 
temporal bone, and extension to the labyrinth, so that the 
prognosis must be regarded as unfavorable. 

Nothing definite is known in regard to the frequency of 
true diphtheria in the ear. It is certainly very rare, and 
does not bear any proportion to the frequency of scarlatinal 
diphtheria. 

3. It has been demonstrated by anatomic investigations — 
among which those of Wendt and Lommel ^ are worthy of 
special mention — that even without clinical appearances, 
and certainly without any involvement of the drum mem- 
brane, certain alterations are regularly found in the middle 
ear of diphtheric cadavers which we must regard as due to 
catarrhal otitis media with or without serous exudation, 
catarrhal otitis media without purulent but with mucous 
secretion, or acute purulent otitis media. Although 
Lommel found pus in the middle ear in one-half of his 
cases, the ear-drum was never perforated nor even markedly 
congested, showing that a clinical diagnosis based on the 
appearance of the otoscopic image would have been 
impossible. 

This explains why the anatomic findings of Lommel in 
regard to the frequency of aural complication in diphtheria 
are in direct opposition to clinical observations. While, on 



1 " Zeitschr. f. Olir.," xxix, cases VII and xxiv, p. 301. 

2 "Zeitschr. f. Olir.," XXIX, p. 301. 
10 



146 ACUTE INFECTIOUS DISEASES. 

the one hand, Lommel found the ear intact in only i out of 
25 autopsies of diphtheric cadavers, and therefore laid down 
the rule that otitis media forms an integral part of the 
clinical picture of " diphtheric disease of the respiratory 
organs," Baginsky,i on the other hand, reports that 
although he examined the ears of his diphtheria patients 
with the greatest care, he found only from 5^ to 6^ in 
which an inflammation was present. Hence we must not 
overestimate the significance of these findings from a clin- 
ical point of view, and as in my cases the reports show that 
the alterations in the mucous membrane of the middle 
ear were very slight and analogous to those which are 
found in other infectious diseases, — especially measles 
(Rudolf and Bezold), — we must assume that they undergo 
regeneration without giving rise to any clinical symptoms. 

As has been stated in connection with croupous inflam- 
mation of the middle ear, the tube may remain intact. 
Lommel found that the cartilaginous extremity was rarely 
attacked, while the "main central portion" was regularly 
free from any inflammatory process, even in one case where 
there was a diphtheric exudate about the orifice itself. 
Hence, direct extension of the inflammation from the 
pharynx to the middle ear is to be regarded as unusual, 
the middle-ear disease being rather the expression of the 
general infection ; and I may remark that, in harmony with 
this statement, consecutive ear disease after nondiphtheric 
tonsillitis, whether of the catarrhal, lacunar, or suppurative 
variety, is rare, notwithstanding the fact that those diseases 
are usually referred to in the text-books as frequent etio- 
logic factors in suppuration of the middle ear. 

Lastly, it appears that nerve deafness may occur after 
diphtheria ; it is probably due to toxic influences, and be- 
longs to the class of postdiphtheric palsies. The cases 
reported are so few ^ ^ and so incomplete that it is impos- 
sible to draw any conclusions from them. 

1 " Diphtheric und diphtheritischer Croup," in Nothnagel's *' Spec. Path. 
u. Then," Bd. ii, i. Th., p. 258. 

2 Kretschmann, '<Arch. f. Ohr.," xxrii, p. 236. 

3 Haug, " Die Krankh. des Ohres," etc., p. 69. 



ERYSIPELAS. 1 47 



JO. ERYSIPELAS. 

Primary erysipelas of the mucous membrane of the upper 
air-passages is a very rare occurrence, and its pathology 
and clinical course can not readily be distinguished from 
those of other infectious diseases of the mucous membrane 
attended with high fever, redness, swelling, edema, and lead- 
ing finally to abscess formation. Indeed, various authors 
have objected to applying the term erysipelas to any dis- 
ease of the pharynx or larynx. Kuttner ^ and Semon ^ 
are probably quite right in advocating the adoption of the 
general term "acute septic inflammations of the larynx," 
rejecting the terms erysipelas of the pharynx and larynx, 
phlegmon, angina (Ludovici), or acute edema of the pharynx 
and larynx as being merely synonymous terms for the same 
clinical picture. Cases of undoubted erysipelatous infection 
of the mucous membranes of the throat, while rare, are none 
the less of the highest importance, as primary erysipelas of 
the mucous membrane of the nose, pharynx, larynx, and 
mouth may, by extension to the external skin, give rise to 
secondary facial erysipelas. This once occurred in 
Schwartze's ^ ear clinic : a patient who had had a pharyn- 
geal tonsil removed went to see an erysipelatous patient 
and contracted erysipelas of the nasopharynx, which spread 
through the tubes to the middle ear, and from there to the 
external meatus, the auricle, and the face. Rendu ^ saw a 
case of erysipelas, where the diagnosis was confirmed by 
bacteriologic examination, in a man suffering with syphil- 
itic glossitis ; there was a fresh rise in the temperature when 
the erysipelas spread to the face. Garel ^ describes a case 
of erysipelas which began in the tongue and reached the 
face by way of the pharynx and nose. 

Erysipelas occasionally occurs as a remote consequence 
of disease of the anterior nares, of the auricle, and of the ex- 
ternal auditory meatus, for excoriations and rhagades due 
to chronic eczema may form the port of entry for the germs 
of the disease. That this is the mode of infection is proved 
by the subsequent extension of the erysipelas, which in 

^ " Larynxodem und submukose Laryngitis," Berlin, 1895, Georg Reimer. 

2" Med. chirurg. Transactions," vol. LXXVIII, 1895. 

^ " Arch. f. Ohr.," vol. xxxviii, p. 213. 

*" France m6d.," 1892 ; see " Semen's Centralbl.," x, p. 131. 

5 " Ann. des malad. de I'oreille," etc., 1891, No. 5. 



148 ACUTE INFECTIOUS DISEASES. 

such cases first appears in the neighborhood of the nose 
and ear, and gradually extends fi-om those points to the 
skin of the face and head. This variety often shows a ten- 
dency to recurrence, and habitual facial erysipelas 1 is 
usually due to chronic eczema of the nose or of the ear. 

This etiologic sequence is important from a therapeutic 
point of view, as the occurrence of erysipelas can be 
guarded against only by combating the eczema and the 
basal disease which is responsible for the eczema, such as 
chronic rhinitis or suppuration from a neighboring cavity 
or from the ear. 

A suppuration from the middle ear due to erysipelas, 
like any other suppuration, may extend to the labyrinth and 
produce symptoms in that locality, as shown in a case 
reported by Schwartze. I can not imagine what Haug ^ 
means when he says that " the internal ear itself probably 
escapes, in some cases at least, in so far as the inflam- 
mation does not extend to the labyrinth ; at most there 
may be signs of a temporary congestion," nor am I much 
impressed by the elegant phrase that " erysipelas not 
rarely reaches its terminal phase in the periauricular lym- 
phatic glands." 

iU MALARIA, 

We find numerous statements in regard to the occur- 
rence of vasomotor rhinitis and hydrorrhoea nasalis in 
malaria. Chapell ^ has collected a series of cases in which 
the hydrorrhea occurred periodically, corresponding to the 
malarial attacks. 

Whether epistaxis is to be regarded as a characteristic 
symptom of the disease or not, is still a matter of doubt. 

According to Lori,'* we rarely have in malaria the 
" typical occurrence of aphonia." On various occasions he 
observed hoarseness or aphonia, synchronous with the 
attack, occurring as early as the algid stage and disap- 
pearing as the temperature fell. In these " intermittent 
aphonias" he always found, "on laryngoscopic examina- 
tion, paralysis of all the muscles supplied by the recur- 

^ Comp. Friedrich, " Pachydermie im Anschluss an habituelles Gesichts- 
erysipel," "Miinch. med. Wochen.," 1897, No. 2. 

2 " Die Krankh. des Ohres," etc., 1893, p. 107. 

3 See " Semon's Centralbl.," xi, pp. 395 and 508. 
* " Die Veranderungen des Rachens," etc., p. 156. 



MALARIA. 149 

rens — sometimes only on one side, sometimes on both." 
Edema of the larynx, according to him, is an occasional 
symptom of the malarial cachexia. 

Haug 1 has given us a comprehensive presentation of 
malarial diseases of the ear in which the literature is fully 
quoted. Protozoic origin has been assumed for certain 
diseases of the ear which occur in periodic attacks, corre- 
sponding to the type of malaria, at intervals of from one to 
three days, and present the picture of an acute inflammation 
of the middle ear or of nervous deafness without being neces- 
sarily accompanied by other malarial symptoms. Even the 
older physicians were well aware of the fact that intermittent 
otalgia sometimes occurred in the course of intermittent 
fever, and Schoenlein ^ states that the neuralgia may be 
localized in the posterior auricular nerve and in the chorda 
tympani, which, as Voltolini adds in explanation, "shows 
that the pain is felt in the interior of the ear, as the chorda 
tympani itself is not capable of giving rise to neuralgia." 

As Weber- Liel ^ was the first to point out the connection 
between "otitis intermittens" with malaria, and gave clinical 
histories in support of his assertion, I shall quote his de- 
scription of the form of malaria which is attended with acute 
irritation of the ear : " After an attack of tonsillitis and 
catarrh of the nasopharynx, at least in most cases, the aural 
affection usually appears toward evening or during the 
night, accompanied by chills, which may be more or less 
marked or only barely perceptible. At first there is only 
an uncomfortable sense of fullness and buzzing in the ears, 
while not rarely a feeling of pressure in the head and vertigo 
are among the first symptoms. The patient passes a 
restless night, perspires profusely, but feels quite well on the 
following day." These phenomena recurred after the man- 
ner of malaria for two or three days ; the ear-drum and the 
external meatus were very hyperemic ; the middle ear was 
the seat of a serous or serosanguineous exudate cor- 
responding in quantity to the frequency of the attacks, and 
in some cases perforation of the ear-drum occurred, 
followed by serosanguineous or purulent discharge, as was 
also observed by Haug.^ For an explanation of this symp- 

^ " Die Krankh. desOhres," etc., p. 145. 

2 Quoted by Voltolini, " Men. f. Ohr.," 1S78, p. 57. 

3 "Mon. f. Ohr.," i87i,p. 125. ^ " Mon. f. Ohr.," 1S78, p. 59. 



150 ACUTE INFECTIOUS DISEASES. 

tom-complex we are driven to assume a trophoneurosis of 
the trifacial nerve. 

Of the second form of malarial disease Garzia ^ gives the 
following description, based on the observation of 24 cases : 
After a rise of temperature, pain and deafness appear in both 
ears, the pain disappearing as the fever subsides, while the 
deafness remains. According to Haug, all kinds of subjective 
noises may make their appearance periodically. 

The diagnosis for both forms of the aural disease is based 
on the intermittent type, the exposure of the patient to 
malarial infection, and the beneficial effects of quinin, which 
are said to be very striking and even capable of curing the 
deafness of the second form. 

1 " Verhandl. des internal. Congresses in Rom," reported in "Arch, f. 
Ohr.," XXXVII, p. 258. 



VII. CHRONIC INFECTIOUS DISEASES. 



U TUBERCULOSIS AND LUPUS. 

Tuberculosis manifests itself in all its various forms in 
the upper air-passages. The anatomic process is analogous 
to that seen in all mucous membranes, presenting as its 
chief type that of tuberculous infiltration, with tubercle 
formation in the submucosa and mucosa, followed by ulcer- 
ation and granulation. It will be shown in a later chapter 
how these fundamental types can readily be classified by 
their clinical appearances into separate subdivisions, which 
tend to make the picture of tuberculosis appear somewhat 
more complicated than it really is when its mode of origin 
is thoroughly understood. But before going into that 
question we must adopt some theory as to how tuber- 
culosis originates in the upper air- passages. The 
mode of infection has given rise to much discussion, and 
various opinions have been advanced in regard to the path 
by which the tubercle bacillus, the causative agent in all 
the various forms, effects an entrance into the tissues. 
The mode of origin depends largely on whether the 
tuberculosis is considered as a primary or as a secondary 
disease, since if the pathogenic germs first become localized 
in the upper air-passages, the infection maybe derived from 
the inspired air and the food ingested ; while if we assume 
a primary tubercular focus in other organs, — as, for instance, 
the lungs, — secondary infection of the upper air-passages 
may take place either from within, by way of the lymphatic 
and vascular channels, or from without, by direct infection 
of the mucosa through the agency of tubercular sputa. 
The first of these two groups — that of primary tuberculosis 
of the throat, nose, and larynx — is comparatively rare. It 
is only recently that it has achieved general recognition, 
and in the case of the larynx, its existence is still a matter 
of dispute. The most recent studies in the mode of tuber- 
cular infection have led to the careful investigation of the 
various lymphatic elements in their relation to tuberculosis, 
151 



152 CHRONIC INFECTIOUS DISEASES. 

Though formerly primary tuberculosis of the palatal, lin- 
gual, and pharjaigeal tonsils was not believed to occur, the 
present tendency, since Strassmann's ^ investigations, — in 
the course of which he found tonsillar tuberculosis in 13 
out of 21 tuberculous cadavers, — is to regard not only 
tuberculosis in general, but also primary infection of the 
pharyngeal lymphatic ring as of comparatively frequent 
occurrence. Clinical observation has not been able to keep 
pace with anatomic investigation on account of the difficulty 
of diagnosing latent tonsillar tuberculosis with any degree 
of certainty. The palatal and pharjmgeal tonsils show no 
macroscopic alterations in cases in which they appear mani- 
festly tuberculous under the microscope ; as a rule, they 
were found to be only slightly hypertrophied, while in a 
somewhat larger proportion of cases small atrophic and 
brawny nodules were observed. As far as I know, Ruge's ^ 
case, in which the clinical diagnosis of latent tonsillar tuber- 
culosis was confirmed by subsequent examination of the 
extirpated tonsils, is the only one of its kind, and even in 
this case the symptoms were very vague. The patient, a 
girl eighteen years old, had had "enlarged tonsils" since 
childhood, and for some time had complained of a vague 
feeling of discomfort in the throat ; later. Pott's disease of 
the cervical vertebrae developed. A few cases ^ have been 
reported in which extirpation of the pharyngeal or palatal 
tonsils was followed by a fatal pulmonary tuberculosis 
within a period of from one to two years, probably as the 
result of a recrudescence of a latent tonsillar tuberculosis 
and the effect of surgical interference. Tuberculosis of 
the lymphatic structures of the pharynx is usually at- 
tributed to direct bacillary infection by the respiratory air 
current or the food ; and it is not necessary in either of these 
modes of infection to suppose an abrasion of theepithehum 
which should afford a port of entry to the pathogenic germs, 
for Stohr, ^ Suchaneck, ^ and Lexer ^^ have been able to 
demonstrate the possibility of the germs gaining entrance 
through sound mucous membrane of the pharyngeal struc- 
tures. This affords a strong argument for the possibility 
of a latent tonsillar tuberculosis giving rise to a descending 

1 " Virch. Arch.," xcvi, p. 319. * " Virch. Arch.," cxLiv. 

3 Kafemann, " Bresgen's Samml.," U, H. 4-5. 

* " Virch. Arch.," XCVH. 

5 " Ziegler's Beitrage," l888. « " Arch. f. klin. Chir.," Bd. Liv. 



TUBERCULOSIS AND LUPUS. I 53 

tuberculous infection of the cervical lymphatic glands. 
The relation of such cases to those in which there is a co- 
existent tuberculosis of the lungs and larynx — that is to 
say, whether they represent a primary infection which has 
become latent, or one secondary to the pulmonary and laryn- 
geal affection — can not at present be determined with cer- 
tainty. A few authors maintain the possibility of primary 
tuberculosis of the pharynx, but its occurrence is at least 
doubtful. 

The study of tuberculosis of the nose has established the 
possibility of primary tuberculosis in this organ. This 
statement is based not only on clinical investigations, — in 
many cases all the other organs were found to be free from 
tuberculosis, — but also on the favorable effect of removing 
the tubercular tumors which are often found on the 
cartilaginous septum ^ of the nose. It is evident that in 
this form of nasal tuberculosis we have to deal with a pri- 
mary infection. This region of the septum plays an impor- 
tant part in the pathology of the nose, as it is the point 
where the inspiratory air current first impinges on the sep- 
tum after passing through the vestibule, and deposits any 
foreign body which it may contain. In this way erosions 
on the septum occur which lead to the sequel known as 
xanthosis, and it is at this point, where the nutrition is nor- 
mally low, that the tubercle bacillus is apt to establish 
itself in favorable subjects and to lead to tubercular ulcera- 
tion or tumor formation. 

Primary tuberculosis of the larynx must be regarded as 
exceptional ; indeed, we should be inclined to deny its 
occurrence altogether were it not for the positive postmor- 
tem proof afforded by the two examples of Orth and 
Demme and the statement of M. Schmidt, based on a large 
experience, that " it is particularly apt to occur in the form of 
tumors on the vocal cords and ventricular bands," although 
M. Schmidt himself points out the lack of postmortem evi- 
dence. The theory of primary tuberculosis of the larynx, 
which is doubted even by Stork and Schrotter, finds little, 
if any, confirmation in Aronsohn's paper, ^ as his cases are 
not above criticism, and an analysis of cases published else- 
where yields only three instances where the lungs were 

1 Chiari, "Arch. f. Laryng.," I. Koschier, " Wien. klin. Wochen.," 
36, 37, 39> 40-42, 1895. 
^ " Arch. f. Laryng.," V. 



154 CHRONIC INFECTIOUS DISEASES. 

found intact at the autopsy. We can not admit as proof 
of primary laryngeal disease cases in which the lungs 
are found to be affected at the autopsy, even when we find 
the assertion that the lung disease is of more recent origin 
than the laryngeal affection. Primary tubercular chondritis 
and perichondritis may possibly occur ; cases of perichon- 
drial tubercular abscess on the exterior surfaces of the thy- 
roid cartilage, unaccompanied by other laryngeal or pul- 
monary manifestations, are occasionally met with, and, as I 
have had occasion to observe, such cases, if operated on, 
yield a favorable prognosis. Angelot ^ and Catti ^ have 
described cases of acute miliary tuberculosis beginning in 
the pharynx and larynx. Angelot's case terminated fatally 
in from two to six months ; the two cases by Catti on the 
eighth and ninth day, respectively. The latter author 
emphasizes the fact that the laryngeal symptoms may be so 
prominent as to mask any morbid symptoms in other 
organs and to suggest diphtheria. 

The most frequent, not to say regular, form of infection 
met with in the upper air-passages is the secondary one ; 
but here again opinions diverge as to whether the infection 
is brought about by direct contact with the infected 
sputum or through the lymphatics and blood-vessels. 
The former opinion may be called that of the morbid 
anatomists, as we find among its representatives such names 
as Orth ^ and E. Frankel,* while the other is held chiefly 
by laryngologists, such as Korkunoff (v. Ziemssen's 
clinic),^ Schnitzler, Schrotter, and others ; but it is worthy 
of remark that neither of the two factions considers its own 
view as the only possible explanation, and admits the pos- 
sibility of the opposite mode of infection in isolated cases. 
Orth says : " When we hav^ to deal with a typical case, 
where, perhaps, there is only a large ulcerated cavity in 
one apex ; where all the bronchi through which the secre- 
tions from this cavity must pass during expectoration are 
full of tubercular ulcers ; where we find smaller ulcers only 
on that side of the main bronchus and lower portion of the 
trachea which, from the position of the body, must come 
into contact with the secretion, and the ulcers are found 

1 Quoted by Orth, p. 323. 2 a Wien. klin. Wochen.," 1894, p. 438. 

3 " Lehrb. der spec. path. Anat.," p. 320. 

■i"Virch. Arch.," cxxi, p. 523. 

5 " D. Arch. f. klin. Med.," XLV, p. 43, 



TUBERCULOSIS AND LUPUS. I 55 

to increase in size and frequency as we ascend ; where, 
omitting a part of the trachea, the tubercular affection 
is seen to be more extensive wherever the walls of 
the air-passages are approximated, and the sputum is there- 
fore forced against the sides, — the conclusion seems inevi- 
table that the sputum constitutes the vehicle by which the 
tubercular toxin is conveyed from the cavity and deposited 
during its transit through the air-passages on favorable 
regions of the mucous membrane." Such "inoculation " 
is, of course, quite conceivable, and the formation of ulcers 
by the entrance of bacilli from the exterior, either through 
excoriations or through the intact epithelium, is possible ; 
but, instead of regarding it, with E. Frankel, " as the essen- 
tial and primary mode of infection," would it not be more 
logical to view it only as an occasional factor in the etiology 
of the disease ? 

The strongest argument in the hands of those who 
believe that the infection takes place through the vascular 
and lymphatic channels is found in the morbid anatomy of 
laryngeal tuberculosis. The first stage of the disease is 
characterized by the deposition of tubercles within the 
mucosa at a greater or less distance from the epithelium, 
which at first retains its integrity ; in fact, there is fre- 
quently a broad, wide zone of healthy tissue between the 
infiltration and the epithelium. In the laryngoscopic image 
tubercular infiltration of this kind, which may become quite 
extensive through the subsequent formation of a large num- 
ber of tubercles, manifests itself in a circumscribed swelling 
covered with healthy mucous membrane. These condi- 
tions can be studied in preparations of tubercular larynges, 
and thus we have a confirmation of the excellent descrip- 
tions given at first by Heinze,^ and more recently by Kor- 
kunoff 2 and others. It is only later, when the tubercle 
increases in size and reaches the level of the epithelium, 
that the latter begins to degenerate ; the membrane be- 
comes loosened and the epithelium breaks down into 
detritus. In this way a tubercular ulcer is formed, the 
superficial necrosis keeping pace with the progress of the 
tubercular infiltration. The distribution of the tubercle 
bacilli also corresponds with these anatomic conditions. 
Korkunoff found that while the outer layers of the epithe- 

1 "Kehlkopfschwindsucht," Leipzig, Veit & Co., 1879. 

2 " D. Arch. f. klin. Med.," vol. .KLV, p. 43. 



I 56 CHRONIC INFECTIOUS DISEASES. 

Hum contained few bacilli, the deeper portions, nearer the 
tubercles, contained large numbers. The anatomic condi- 
tions, therefore, would appear to show that the tubercular 
process spreads by way of the lymphatic or vascular chan- 
nels, and this is in accord with daily clinical experience, 
for we frequently find that apparently harmless thicken- 
ings, especially on the posterior wall, often undergo a 
bluish discoloration, become necrotic, and are converted 
into ulcers, so that it does not seem plausible in these cases 
of tubercular infiltration to suppose an infection by contact 
notwithstanding that Orth refuses to admit the explanation 
of the subepithelial appearance of the tubercles. There 
is no doubt that tubercles produced by contact do occur 
in the epithelium of the larynx, but they are of an entirely 
different nature, both anatomically and clinically. They 
were formerly described as diphtheric (Rokitansky), then 
as aphthous erosion and corrosion ulcers ; a difference of 
opinion concerning their origin existed for a long time, as 
it seemed doubtful whether they should be explained as 
simple tubercular or merely as arrosion ulcers, due either 
to irritation of the mucous membrane by the contents of 
the cavity or to a secondary infection of superficial ero- 
sions. 

These ulcers are not the result of an infiltration, as was 
formei-ly believed, but represent superficial miliary tubercle 
nodules in process of degeneration. They form flat super- 
ficial ulcerations with a decided tendency to spread, while 
the tendency to form granulations in the floor of the ulcer, 
which is such a marked clinical characteristic of other 
tubercular lesions, is absent. The floor of the ulcer is 
covered by a thick, yellowish exudate, which sometimes 
forms a true fibrinous membrane slightly raised above the 
level of the surrounding parts. It is probably this appear- 
ance that induced Rokitansky to describe them as diph- 
theric ulcers. 

These arrosion ulcers represent, therefore, another spe- 
cific expression of the tubercular process, ultimately due to 
the action of the tubercle bacilli, but their mode of infec- 
tion is evidently quite different from that which I have so 
far described. Since from the very beginning of the disease 
the tubercular infiltration is superficial, we can not in this 
case suppose a movement of the bacilli from within outward, 
— in other words, from the vascular or lymphatic channels, 



TUBERCULOSIS AND LUPUS. I 5/ 

— and must admit the explanation of an infection by con- 
tact with tubercular sputum. The significance of a mixed 
infection with staphylococci and streptococci has not as yet 
been determined, but such an infection appears probable 
when we consider the rapid spread of these ulcers. 

Certain clinical arguments have been advanced to 
prove the occurrence of infection from the lungs and 
larynx through the blood-vessels, but the observations of 
Friedreich, Schrotter, and Schech (which were not con- 
firmed by Heinze's postmortem investigations), that the 
disease always affects the organs on the same side, are not 
above criticism. If we accept direct infection of the larynx 
as the rule, it is at least remarkable that when the expectora- 
tion is very copious and contains bacilli, there is no laryn- 
geal disease ; whereas it is present in cases when there is 
little or no sputum in a beginning pulmonary tuberculosis, 
and there is therefore no possibility of long-continued con- 
tact of the sputum with the mucous membrane, favoring 
the entrance of the bacilli. To meet this objection, Orth 
assumes a certain constitutional predisposition or weakness 
of the mucous membranes to explain the occurrence of in- 
fection by contact. But if contact with the sputum plays 
such an important role in predisposed individuals, why does 
the disease become localized in the larynx ? Does not the 
squamous epithelium in the deeper portion of the pharynx, 
in the pyriform sinuses, and on the posterior and lateral 
pharyngeal walls present the same possibility of infection 
from without as the epithelium of the larynx, which shows 
a special preference for tubercular disease in those portions 
covered by squamous epithelium ? The sputum collects in 
much larger quantities in these regions than it does in the 
larynx itself, where it is constantly expelled by reflex cough, 
and therefore infection by contact would be quite as likely 
to occur as in the larynx ; but, as a matter of fact, this is 
not the case. We know from the observation of other 
laryngeal diseases, especially carcinoma, that enlargement 
of the lymphatic glands and extension to the surrounding 
structures occur only in the later stages of the disease, 
and it appears that the lymphatic system of the larynx 
occupies, in a certain sense, a unique position. Of course, 
we can not as yet say with any certainty that this factor in 
any way contributes to the tendency of the infection to 
localize itself in the larynx, to the exclusion of other por- 



158 CHRONIC INFECTIOUS DISEASES. 

tions of the upper passages, but the observation is worthy 
of consideration. 

We therefore reach the conclusion that both views in re- 
gard to secondary infection of the larynx from the lungs 
have their pros and cons, and that it is impossible to draw 
any absolute theoretic deductions in support of either 
theory. In view of our clinical and anatomic experience, 
we recognize infection of the larynx by way of the lymph- 
channel, as probably more frequent, and reserve infection 
by contact for those cases which manifest themselves in the 
form of arrosion ulcers. 

Tuberculosis of the nose manifests itself in three different 
forms : 

{a) Tuberculoma. 

ib) Extensive infiltration with ulceration. 

ic) Bone disease with secondary extension to the mucous 
membrane. 

The typical seat of tuberculous tumors is the cartilag- 
inous septum, although in a few cases they are found on 
the bony portion. They appear as tumors w^ith a broad 
base, imperfectly circumscribed, and of varying size, so that 
they lead to a greater or less constriction of the nasal cavity. 
The epithelium is usually preserved and appears healthy on 
the surface ; the mucous covering is smooth ; the surface is 
either uniform or slightly bosselated ; occasionally, several 
distinct nodules can be made out on the tumor. They show 
very little tendency to ulceration and caseation of the con- 
tained tubercle ; it is only in very old cases that there is 
occasionally seen a tendency to ulceration at the apex of 
the tumors (Koschier). The swelling usually appears first 
on one side of the septum, but later a similar swelling is 
seen on the opposite side, so that we have two dark-red or 
grayish-red tumors, which can be seen without the aid of 
a reflector and resemble traumatic abscesses of the septum. 

In this stage of the disease the perichondrium becomes 
the seat of round-celled infiltration ; the process invades 
the cartilage of the septum, which undergoes necrosis ; the 
dividing wall between the two tumors breaks down, and 
they become fused. This destructive process may go on for 
years without any marked alteration in the clinical picture. 
In some cases, however, the surfaces become ulcerated and 
the tubercular tumor undergoes further disintegration, and 



TUBERCULOSIS AND LUPUS. I 59 

finally becomes merged in the ulcerative process which at- 
tacks the deeper tissues. 

As the septum has already been attacked by the morbid 
process, the loss of tissue now becomes evident by the de- 
struction of the tuberculous granulation ; usually, the greater 
portion of the cartilage is found to have been destroyed, 
while the bony septum always escapes. Although now 
the most conspicuous symptom of the clinical picture is the 
perforation of the septum, the granulations and nodules 
found at the edge of the perforation furnish a valuable diag- 
nostic sign to distinguish it from perforating ulcer of the 
septum, in which the edges are smooth and sharply defined. 
This form of destruction of the septum is not followed by 
any alterations in the external nose. 

The subjective symptoms, which consist in obstructed 
nasal respiration, are at first insignificant, but increase with 
the growth of the tumor. Their appearance is occasionally 
preceded by epistaxis. The formation of crusts is no part 
of the clinical picture as long as the integrity of the epithe- 
Hum is preserved, but it appears as soon as ulceration has 
begun. 

It is convenient to mention the so-called scrofulous alter- 
ations in the nose in connection with the tuberculomata, 
which Koschier, from their histologic structure, describes 
as tuberculoscrofulous lymphomata. Scrofula, as a separate 
process, has ceased to enjoy the recognition it formerly had, 
and is now generally regarded as a manifestation of tubercu- 
losis peculiar to the childish organism. In addition to con- 
stitutional phenomena, it finds expression in chronic eczema, 
with infiltration of the skin at the anterior nares and the 
upper lip, where it produces the characteristic thickening of 
the scrofulous habit. The disease strongly resembles 
chronic dermatitis, for it is localized almost exclusively in 
those regions of the skin which are covered with epidermis, 
and it is at least doubtful whether we are justified in dis- 
tinguishing the eczema of " true scrofula " from the form 
which often occurs in children as the result of nasal obstruc- 
tion and consequent chronic rhinitis. Hence, scrofulous 
eczema does not extend beyond the plica vestibuli, which 
forms the boundary between epidermis and mucous 
membrane. Unless we can demonstrate the tubercular 
process in such infiltrations and erosions on the nose and 
upper lip, we can not consider scrofulous eczema as 



l6o CHRONIC INFECTIOUS DISEASES. 

a form of tuberculosis, and as this proof is lacking, and 
scrofulous eczema fails to show any peculiar characteristic, 
we can only designate it as a form of chronic eczema peculiar 
to the scrofulous habit. 

On the other hand, those cases in which the tuberculo- 
scrofulous tumor shows a distinct tubercular structure are 
to be regarded as genuine manifestations of tuberculosis, in 
no way connected with scrofula ; such cases frequently go 
on to granulation and ulceration, with occasional destruc- 
tion of the septum and of the inferior turbinated bone. Al- 
though in practice the conception of scrofula as a distinct 
morbid process may be expedient, it can not be denied 
that the term is often used to cover many processes in the 
childish organism for which as yet no satisfactory explana- 
tion has been found, and it is consequently advisable to re- 
strict its application as much as possible. 

The second or ulcerated form of nasal tuberculosis presents 
the characteristics of ordinary tuberculosis affecting mucous 
membranes. Infiltrations going on to degeneration, with the 
formation of ulcers with infiltrated edges and covered with 
granulations (Schech ^ stands alone in describing them as 
poor in granulation tissue), form the anatomic basis and 
lead to a more or less extensive destruction of the nasal 
mucous membrane, which can be demonstrated clinically. 
The ulcers vary in depth, and may spread to the bones and 
cartilages, where they lead to necrosis and deformities in the 
bony and cartilaginous framework. 

In this form of the disease the principal symptoms are at 
first epistaxis, the formation of crusts of dried secretions, 
and the discharge of mucopus, so that it was formerly 
described as a tubercular ozena. 

When the bone is involved, there might be some diffi- 
culty in distinguishing the condition from syphilitic disease, 
were it not for the fact that in every case of advanced nasal 
tuberculosis undoubted signs of tuberculosis are found in 
the lungs, for it appears from the observations published 
thus far that this form of tuberculosis always occurs 
secondary to extensive tubercular disease of the lungs. 

Finally, there is a third form of nasal tuberculosis, begin- 
ning in the bone or cartilage, which Koschier ^ described on 
the strength of a single observation, although it is in accord 

1 " Krankh. der Mundhohle," etc., Fifth Edit., p. 317. 

2 " Wien. klin. Wochen.," 1896. 



TUBERCULOSIS OF THE PHARYNX. l6l 

with earlier descriptions by v. Volkmann, who observed 
this form of the disease quite frequently. Nevertheless, 
I am inclined to consider it much less frequent than the 
other two, especially the tumor-like variety, which I have 
often observed myself, while I have yet to see my first 
example of the former variety. I shall therefore quote 
the description given by Koschier, in which three factors 
are emphasized as characteristic of this form of the disease. 
These are, in the first place, alterations in the form of the 
external nose, which, as has been said, do not occur in the 
other forms ; the wide distribution of the disease, which 
does not confine itself to one side of the septum, or even 
the entire septum, but takes in almost the entire skeleton 
of the nose ; and, finally, the comparatively early appear- 
ance of large, deep ulcers in the mucous membrane, together 
with extensive necrosis, and the separation of necrotic por- 
tions of the cartilage and bone. These are the diagnostic 
points which serve to distinguish it from the variety of nasal 
tuberculosis which originates in the bony and cartilaginous 
portions. 

Tubercular disease of the ///«;^^;/,r is infrequent. Tuber- 
culomata on the posterior surface of the uvula (AvelHs ^) 
and on the roof of the pharynx (Koschier ^) must be 
regarded as extremely rare. Mouret ^ described a unique 
case of tubercular granulations about the size of a bean 
appearing on the palatal tonsil of a patient twenty years of 
age, suffering from pulmonary and laryngeal disease. 

The ulcerated form, first described by Isambert,* occurs 
more frequently. The anemic mucous membrane is the 
seat of closely aggregated grayish nodules about the size of 
a split pea, which later coalesce and break down. The 
ulcers, which have been minutely described and designated 
as " lenticular" by B. Frankel,'^ are characterized by a ten- 
dency to grow toward the periphery rather than to invade 
the deeper tissues. The edges of the ulcer are slightly 
infiltrated and are irregular in outline, while the floor is 
covered with minute granulations and a dirty yellow secre- 
tion. In accordance with the superficial seat of the ulcers 
there is no diffuse infiltration of the mucous membrane, 

1 "Deutsche med. Wochen.," 1891, Nos. 32 and 33. 

2 Loc. cil. 3 "Rev. hebd. de lar.," 1896, No. 54. 
•* " Ann. des mal. de I'oreille," I, 1875, p. 77, and 11, p. 162. 

5 " Berlin, klin. Wochen.," 1876, No. 46. 
II 



162 CHRONIC INFECTIOUS DISEASES. 

such as is seen in the larynx. These ulcers are found 
chiefly on the soft palate and on the uvula ; sometimes on 
the anterior and posterior arch of the palate and on the 
lateral pharyngeal wall ; and in rare cases on the posterior 
pharyngeal wall and in the postnasal space. Although the 
ulcers are superficial, they nevertheless produce extensive 
destruction in the soft palate, but they have never been 
known to attack the bone. The subjective symptoms con- 
sist in dysphagia, and often in violent pain radiating toward 
the ears. In some cases partial cicatrization is said to 
occur, Kraus ^ reports having seen adhesions of the soft 
palate.; but these accidents are rare, for there is very little 
tendency to spontaneous cure. Hence the prognosis in this 
form of pharyngeal tuberculosis, characterized by the pres- 
ence of miliary nodules with a tendency to degenerate, is 
very unfavorable. The great majority of cases, as pointed 
out by Isambert, occur in the last stages of pulmonary 
phthisis, and this fact is of value in the diagnosis, which 
occasionally presents difficulties to the novice, who might 
be in danger of mistaking the tubercular for syphilitic ulcers. 

Another manifestation of tuberculosis in the pharynx is 
seen in the cold abscesses which sometimes occur in the 
posterior pharyngeal wall, and are due to carious disease 
of the vertebral column. They give rise to a fluctuating 
tumor about the size of a hen's egg, usually on one side 
of the posterior pharj-ngeal wall, at a level varying with 
the particular vertebra affected. The patient complains of 
a sensation as of a foreign body in the throat when he 
swallows, and the voice has the well-known palatal quality. 
The presence of these symptoms of primaiy vertebral dis- 
ease differentiates the diagnosis from tumors or other 
varieties of abscesses. 

In the larynx we distinguish three forms of tuberculosis : 
One characterized by infiltration followed by degeneration ; 
superficial ulcers (arrosion ulcers) ; and, finally, the tumor- 
like variety — tuberculoma. The most frequent form of the 
disease is the first-mentioned, and it presents such typical 
phenomena that the diagnosis can, as a rule, be easily 
made from the characteristic infiltration and ulceration. 
As the infiltration is due to the formation of tubercles in 
the mucous membrane, and has its seat in the submucosa, 

1 " Nothnagel's Handbuch," xvi, I. Th., I. Abth., p. 276. 



TUBERCULOSIS OF THE LARYNX. 1 63 

the clinical picture varies with the anatomic relations of the 
mucous membrane in the various portions of the larynx, 
the degree of swelling depending on the thickness of the 
submucous tissue ; and according as the mucous membrane 
is or is not in close relation with the other structures in the 
larynx, especially the cartilage, there will be a greater or 
less tendency for the infiltration and ulceration to spread to 
these deeper parts. On the plica vocalis, where there is no 
submucous tissue, the stage of infiltration is less conspicu- 
ous than it is in the interarytenoid space, where the looser 
structure of the submucous tissue presents a favorable 
medium for the development of infiltration and secondary 
edema. Where, as on the epiglottis and the arytenoid 
cartilage, the mucous membrane is closely adherent to the 
cartilage, or in the vocal process, where it is intimately 
joined to the elastic fibers in the cartilage, the infiltration is 
very likely to extend to the perichondrium and to set up a 
perichondritis followed by necrosis of the cartilage ; while, 
on the other hand, if the disease is situated on the ven- 
tricular bands or the aryepiglottic folds, there is less danger 
of its spreading to the adjoining cartilages. 

The most frequent seat of infiltration is the mucous 
membrane in the interarytenoid space, — /. e., the interior 
surface of the posterior laryngeal wall, — so much so that its 
appearance in this situation is almost pathognomonic. In 
the early stages of the disease there is in this region a 
slight swelling, which becomes prominent when the mucous 
membrane is stretched, as in deep respiration. The swell- 
ing is not uniformly distributed over the posterior wall, but 
forms a slight prominence, either in the middle or to either 
side of the median line. It may be distinctly isolated, like 
a tumor, as Tijrck ^ described it, while the covering of 
mucous membrane remains intact. At first there may be 
some difficulty in differentiating these tuberculous infiltra- 
tions from chronic laryngitis, in which the parts are also 
swollen, especially when the entire upper respiratory tract 
shares in the descending catarrh ; the catarrhal swelling is, 
however, diffuse, being due to uniform thickening of the 
mucous membrane. The latter arches forward toward the 
interior of the larynx in the respiratory position, but in the 
median position becomes puckered into folds. The color 

1 " Atlas," I, XVII, vol. II. 



164 CHRONIC INFECTIOUS DISEASES. 

of this catarrhal infiltration is characteristic, being a bluish- 
gray or whitish-gray, in consequence of the catarrhal 
thickening of the epithelial layers. 

In the tubercular variety as the disease progresses the 
infiltration increases in size and its surface becomes nodular. 
At this time functional disturbances begin to appear. The 
accurate apposition of the arytenoid cartilages, on which 
normal function depends, becomes mechanically impossible 
on account of the tumor-like infiltration, and more or less 
pronounced hoarseness develops. The laryngoscopic image 
simulates the appearance of a paresis, as the posterior por- 
tions of the vocal cords fail to approximate on account of 
the swelling. 

The epithelium itself now begins to undergo alteration. 
As the tubercular infiltrate approaches the surface the upper 
layers of the epithelium become necrotic and assume a 
grayish-white discoloration, the surface finally undergoes 
more extensive alteration, and we have the formation of 
ulcers and granulations. 

The tubercular ulcers are characterized by elevated, infil- 
trated margins, which in the laryngoscopic picture largely 
obscure the floor of the ulcer owing to the foreshortening 
of all plane surfaces in the reflected image, so that the true 
condition is sometimes difficult to recognize. The second 
characteristic of tubercular ulcers is a tendency to the 
formation of granulations in the floor of the ulcer, and as it 
is difficult in ordinary laryngoscopy to see all of the poste- 
rior laryngeal wall, it is often impossible to determine 
whether there are deep ulcers or granulating surfaces hid- 
den behind the infiltrations ; it is, however, of little practi- 
cal significance, as the granulations themselves rapidly 
undergo decomposition, and there is throughout the disease 
a continual alternation between granulation and ulcerative 
disintegration. Thus the surface presents an irregular ap- 
pearance, ulcerating areas alternating with papillary masses 
of granulations, and, when seen in profile from above, sug- 
gesting the picture of a chain of mountains with narrow 
valleys running between them. It is well to bear in mind 
that the disease is usually more extensive on the posterior 
wall than appears in the laryngoscopic image. Whether the 
ulcers and granulations extend from the interarytenoid space 
down below the vocal cords, or occupy only the upper seg- 
ment of the posterior wall, the laryngoscopic image will be 



.TUBERCULOSIS OF THE LARYNX. 1 65 

the same, as the elevated infiltrated margins of the ulcers 
completely hide the deeper portions. In such cases it is 
often possible to obtain an approximately correct image of 
the surface by employing Killian's method of examining 
the posterior wall, which consists in having the patient bend 
his head well forward while the operator sits on a low stool, 
or even kneels down in front of him. Even better than 
this is Kirchstein's method, which permits the observer to 
obtain a most satisfactory view of the posterior wall. 

From the interarytenoid mucous membrane the morbid 
process extends to the posterior extremities of the vocal 
cords, which are eventually destroyed. Sometimes large 
flat ulcers extend from the posterior wall to the vocal cords, 
and if the granulations do not happen to be very abundant, 
these may easily be overlooked. ^ On the other hand, 
it must not be forgotten that the arytenoid cartilage is 
occasionally visible through the pallid mucous membrane 
above the vocal processes, and might in that case be mistaken 
for an ulcer. The epiglottis and the aryepiglottic folds 
are favorite seats for the tubercular process, and suffer the 
same destruction that we have described in the case of the 
posterior wall. The course of the disease can readily be 
traced on the epiglottis. The infiltration is the first change 
to appear, and lends a cushion-like shape to the epiglottis, 
which covers the greater part of the interior of the larynx. 
Later, ulceration begins accompanied by the appearance of 
granulations and grayish tubercles the size of a split pea in 
the neighborhood of the ulcer. If the aryepiglottic folds 
are involved there is usually marked swelling ; the lateral 
wall of the larynx is attacked, and after the breaking-down 
of the infiltrated area this may lead to the formation of 
deep ulcers. The infiltrated ventricular bands become so 
swollen that they completely hide the vocal cords ; occa- 
sionally ulcers and granulations are seen in the ventricle of 
the lar^^nx, the former breaking directly through the ven- 
tricular bands into the interior, the latter projecting from the 
entrance like papillomatous tumors. Eventually, the tis- 
sues in all these regions of the upper portion of the larynx 
suffer more or less destruction, as the ulcers show little 
tendency to heal spontaneously by cicatrization, and the 
infiltration constantly tends to spread. 

1 See illustrations in Scbnitzler's " Atlas," Plate ix, Nos. I and 2. 



1 66 CHRONIC INFECTIOUS DISEASES. 

In the vocal cords the tubercular changes in the early 
stages are less pronounced, the catarrhal disease being 
more conspicuous than the infiltrations. The vocal cord 
is red and swollen, and assumes what is usually described 
as a cylindrical form. But even in these early stages 
the distribution of the disease, which often does not in- 
clude the entire vocal cord or is confined to one-half of 
the larynx, points to tuberculosis rather than to catarrh, 
where the changes are usually symmetrical. In rare cases 
a series of tubercular nodules resembling a string of pearls 
is observed on the free border of the vocal cord. In most 
cases, however, the inflammation in the vocal cords is 
followed by destruction of the epithelium, and the forma- 
tion of ulcers covered with a yellowish exudate. It is 
worthy of remark, as pointed out by M. Schmidt, that 
when the vocal cord is covered by a diffuse superficial 
ulceration, the yellowish exudate occasionally makes it 
appear almost normal. No matter how small or superfi- 
cial an ulcer may appear in a tubercular patient, it should 
be regarded as tuberculous, as there can be no question of 
its being a catarrhal ulcer. 

The tissue destruction that takes place in the subsequent 
course of the disease first attacks the free border of the 
vocal cord, and later extends over larger areas. It is 
frequently accompanied by active granulation, forming large 
masses resembling a cock's comb on the vocal cords, and 
in some cases leading to stenosis of the glottis. Some- 
times the swollen and infiltrated vocal cord presents a fur- 
row running parallel with and underneath the free border, 
converting the structure into two separate folds, one above 
the other. A picture of this kind is seen when ulcers 
appear on the lower surface of the vocal cord, or when 
there is a series of ulcers, above described as resembling a 
string of pearls. 

The different forms of tuberculosis described thus far 
may vary in their extent and in the order of their appear- 
ance, and give rise to a great variety of clinical pictures. 
When, however, the infiltration extends to the cartilaginous 
frame of the larynx, the appearance changes, infiltration 
and ulceration of the perichondrium being followed by 
necrosis of the cartilage. The epiglottis and the arytenoid 
cartilages with their vocal processes, being nearest to the 
favorite seat of the disease, are most frequently attacked ; 



TUBERCULOSIS OF THE LARYNX. 1 6/ 

more rarely, perichondritis extends to the crico-arytenoid 
articulation, and from there to the arytenoid and cricoid 
cartilages, the thyroid cartilage being very rarely involved. 

Whenever the epiglottis shows signs of edema, perichon- 
dritis should be suspected. The peculiar structure and 
porosity of the epiglottis, which permit the glands and 
blood-vessels to pass through the cartilage from the laryn- 
geal to the oral surface, allow the infiltration to spread in 
all directions, so that we do not get necrosis of the car- 
tilage, but rather a complete liquefaction. This progresses 
pari passu with the infiltration of the mucous membrane, 
and may end in complete destruction of the epiglottis. In 
addition to the edema which characterizes the disease in 
the epiglottis, there is the symptom of pain, usually de- 
scribed as radiating toward the ears. Sometimes the dys- 
phagia becomes so great that the taking of food gives rise 
to excruciating pain. 

The infiltration, as has been said, is prone to spread from 
the posterior wall to the posterior portions of the vocal 
cords, where the vocal processes present a favorite seat for 
the disease. In this situation redness and swelling first ap- 
pear, sometimes without involving the ligamentous portion 
of the vocal cord, so that the inexperienced observer is led 
to suspect pachydermia. Soon, however, deeper ulcers 
appear in these regions, and microscopic examination shows 
that there is a disintegration of the reticular portion of the 
arytenoid cartilage. Later, the process spreads to the 
perichondrium of the hyaline portion of the cartilage, and 
thus secondary perichondritis is followed by necrosis of the 
cartilage and the separation of sequestra. 

Perichondritis of the arytenoid cartilage produces a char- 
acteristic swelling and edema in the aryepiglottic fold, and 
motion is impeded solely by the mechanical pressure of 
the swelling. Before long, however, the disease spreads 
to the capsule of the crico-arytenoid articulation, and, 
after destroying the joint, attacks the cricoid cartilage. 
This results in interference with the movement of the ary- 
tenoid cartilages, which finds expression in an apparent 
paresis of the vocal cords. Although it has been said that 
an edematous swelling over the affected portion of the car- 
tilage is an important diagnostic point, it may be well, in 
order to avoid a misunderstanding, to point out that it 
has diagnostic value only when it is preceded by the break- 



1 68 CHRONIC INFECTIOUS DISEASES. 

ing down of infiltrations in the areas mentioned, so that if a 
larynx is seen to be affected in this way at the first exam- 
ination, there is always a possibility that one has to deal 
with a simple tubercular infiltration of the mucous mem- 
brane. Deep ulcers in the aryepiglottic folds are very 
often surrounded by edematous areas ; perichondritis of 
the cricoid and thyroid cartilages is rare and presents no 
typical appearances. The diagnosis of the tubercular 
nature of the disease is based on the appearances in the 
other portions of the larynx. There are rare cases in 
which there is a so-called external perichondritis, the 
morbid process appearing on the external surface of the 
cartilage, principally on the lateral plates of the thyroid. 

Lastly, we may mention three symptoms which are 
occasionally described as characteristic of tubercular laryn- 
geal disease : anemia of the laryngeal mucous membrane, 
catarrhal laryngitis, and paresis of the vocal cords. Anemia 
of the nnicoiis membranes is an expression of the general 
phthisical habit, and can not be regarded as a symptom 
of beginning laryngeal tuberculosis. 

The question whether or not there exists a tubercular 
catarrh of the larynx is difficult to decide, and there are 
experienced laryngologists who believe it to be possible ; 
but in those cases where the laryngoscope shows an un- 
complicated image of catarrhal laryngitis it is more scien- 
tific to speak of chronic catarrh of the larynx associated 
with tuberculosis of the lungs than to speak of tubercular 
catarrh, since the latter term is hardly justified by the clin- 
ical and anatomic appearances. Paresis of the vocal cords 
is a symptom that frequently occurs in the beginning of 
tuberculosis and occasionally forms the prelude to tubercular 
disease ; sometimes it appears only periodically after exces- 
sive use of the voice. E. Frankel^ found that it was due to 
atrophy of the muscular fibers, but the question whether 
tubercular changes occur in the muscle so early in the 
disease, or whether we have to deal with simple fatigue of 
the muscle due to anemia, such as occurs in all grave 
organic anemias, can not be determined at present. 

There is another variety of tubercular ulcers differing 
from those following infiltration, which we shall describe as' 
arrosion 7ilcers, due to local tubercular infection by the 

1 " Virch. Arch.," LXXi, p. 261. 



TUBERCULOSIS OF THE EAR. 1 69 

sputa. They are distinguished by their superficial charac- 
ter and their tendency to spread over the surface of the 
membrane. Their favorite seat is the epiglottis, especially 
its free border ; after that, the surface of the larynx, the 
aryepiglottic folds, and the lateral wall of the larynx. 
They begin as small ulcers the size of a split pea, with a 
moderately injected base, and finally become covered with 
necrotic epithelium, which separates and exposes a shallow 
depression. The ulcers run together and tend to spread 
toward the periphery, so that eventually large areas of the 
mucous membrane become involved. They occur princi- 
pally in the later stages of pulmonary tuberculosis, and are 
found usually combined with other tubercular appearances 
in the larynx. 

A rarer form of tuberculosis is found in the tuberculo- 
mata, which appear as circumscribed tumors. We learn 
from an exhaustive analysis of the cases by Avellis ^ that 
they grow most frequently "in the ventricle of the larynx 
under the angle of the glottis and on the posterior wall ; 
more rarely on the ventricular bands ; and least fre- 
quently on the vocal cords." Panzer ^ reports three 
cases of tubercular polyps on the vocal cords from Chiari's 
polyclinic. These tumors frequently do not differ from 
ordinary fibromata of the larynx, and, as a rule, show no 
tendency to ulceration. In some cases they must be 
regarded as a primary localization of the tubercular process, 
as no signs are found in the lungs or other organs of the 
body ; in such cases their true nature can be determined 
only by histologic examination, for they are absolutely with- 
out any clinical characteristics. The prognosis is good if the 
tumors are removed ; M. Schmidt ^ remarks that he often 
observed removal of the tumors to be followed by perma- 
nent cure or by a long period of health, until a new ulcer 
or a hemorrhage of the lungs supervened and confirmed 
the microscopic diagnosis. 



TUBERCULOSIS OF THE EAR. 

While the manifestations of tuberculosis in the larynx, 
though varying in their external appearance, are funda- 

1 " Deutsche med. Wochen.," 1891, Nos. 32 and 23- 

2 " Wein. med. Wochen.," 1895, Nos. 3-5. 

2 " Die Krankh. der ob. Luftwege," 2d edit., p. 362. 



I/O CHRONIC INFECTIOUS DISEASES. 

mentally the same, this is not the case with the organ of 
hearing. In the larynx the diagnosis is readily made, even 
in advanced stages of the disease, by the presence of infil- 
tration, ulceration, and granulation ; but in tuberculosis of 
the ear the clinical picture varies greatly, and there is no 
characteristic course. This may be partly explained by 
the fact that the aural disease at first presents no more 
alarming symptoms than difificult hearing and discharges 
from the ear, and does not come under observation until 
quite late, when the process is so far advanced that it can 
not be distinguished from a simple chronic otitis media. 
Hence it is that the most prominent features of the picture 
are destruction of the tympanic membrane, suppuration and 
abscess formation in the mucous membrane of the middle 
ear, and carious destruction of large portions of the tem- 
poral bone, which separate as sequestra, while the granula- 
tions, which are so characteristic of the tubercular process, 
are comparatively insignificant. 

It is almost superfluous to say that nowadays we base a 
description of tuberculosis of the organ of hearing exclu- 
sively on the demonstration of tubercle bacilli or on the 
histologic appearance characteristic of tuberculosis. We 
merely mention the fact because even in recent times such 
authors as Bezold and Hegetschweiler depend on the 
macroscopic appearance of the clinical picture and neglect 
bacteriologic examinations. That Bezold and some other 
authors differ from most of the authorities in regard to the 
diagnostic significance of tubercle bacilli in suppurative 
aural disease is due to the fact that there is a want of agree- 
ment in the literature as to the presence of tubercle bacilli. 
Among forty cases of otorrhea in tuberculous subjects, 
Nathan found tubercle bacilli in only twelve instances, 
while Lucae was unable to find them once among seven- 
teen patients whom he had inoculated with tuberculin. On 
the other hand, I have rarely failed to find the bacilli, 
although I have examined a large number of cases. 

But this failure to demonstrate the bacillus in every in- 
stance is explained, as already pointed out by Gottstein, by 
the fact that the pus is derived from the tubercular carious 
foci in the middle ear, which, it is well known, often fail to 
show the presence of bacilli. When we consider that, as 
Krause ^ has shown, the finding of bacilli in tubercular 

^ " Tuberculose der Knochen und Gelenke," Leipzig, 1891, p. 7. 



TUBERCULOSIS OF THE EAR. lyi 

bone disease is rare, and when we consider also that we 
often fail to find bacilli in undoubted cases of pulmonary 
tuberculosis, it can not surely be denied that the finding of 
bacilli should be a deciding proof of the existence of the 
disease. It is possible, by using proper methods of staining, 
to avoid the errors which are sometimes occasioned by the 
smegma bacillus. The latter is often found in old, purulent 
foci. Brieger supposes that the tubercle bacilli found by 
Bezold in cholesteatomata were really smegma bacilli, and 
I have myself found them in the pus derived from a sar- 
coma of the ear ; they were easily decolorized with alcohol 
or dilute hydrochloric acid. 

Tuberculosis of the ear may occur in any stage of the 
pulmonary disease, but it presents itself most characteris- 
tically in the later stages. It may be unilateral or bilat- 
eral, although some authors maintain that the left ear is 
more often affected than the right. A universal characteris- 
tic of tuberculosis of the ear is the absence of pain, which 
often leads the patient to neglect the disease as unimportant, 
so that the earlier stages do not come under observation. 

It would appear that tuberculosis in the ear is usually 
secondary. The few cases so far reported as primary are 
open to criticism, and for the present we have no proof of 
primary tubercular osteomyelitis of the mastoid process. 

It is difficult, if not impossible, from the clinical point of 
view, to decide whether one has to deal with primary tuber- 
culosis of the bone, with secondary involvement of the 
tympanic cavity, or with the opposite condition ; accord- 
ingly, we find that opinions are divided on the subject 
(Kiister and Schwartze). But it would seem plausible to 
assume that we have to deal with primary tuberculosis of 
the bones of the ear in those cases in which there is a dif- 
fuse tubercular bone disease with fistula formation in 
scrofulous children. 

Chronic tuberculosis, which is the most frequent form, is 
probably due to infection by way of the lymphatic channels. 
Barnick ^ supposes hematogenous infection in chronic 
tuberculosis of the middle ear to be quite frequent, espe- 
cially in scrofulous children, " in whom, after rupture of 
a cheesy focus containing a few bacilli, the infection car- 
riers are transmitted by the blood." 

1 "Arch. f. Ohr.," vol. XL. 



1/2 CHRONIC INFECTIOUS DISEASES. 

Next in order of importance as a channel of infection we 
have the Eustachian tube. As the mucous membrane of 
the tube shares in the general atrophy characteristic of the 
phthisical habit, the lumen is usually dilated, and readily 
permits the entrance of sputum from the postnasal space. 
If there is ulceration in the nasopharynx, the conditions 
are, of course, even more favorable for infection. This 
mode of infection is perfectly possible, since the bacilli are 
capable of penetrating between the epithelial cells of the 
tympanic mucous membrane, even when the external layer 
of the epithelium is intact. It is further supported by the 
fact that tuberculosis most frequently begins in the mid- 
dle ear. On the other hand, it would appear, from E. 
Frankel's^ observations, that the danger of infection from 
the postnasal space is not very great, for among fifty autop- 
sies of tubercular patients, he found ten cases of tuber- 
cular disease in the postnasal space, without implication of 
the ear. 

We have no means of judging whether it is possible for 
tubercular disease of the middle ear to be produced by 
direct immigration of the tubercle bacillus through a tuber- 
cular infiltration in the tympanic membrane, as there are 
no facts to support such a supposition. 

On the tympanic membrane tuberculosis attacks both 
the epidermis and the mucous membrane. 

The former variety is rare, and lacks histologic demon- 
stration ; it includes only those cases in which there was 
undoubted tubercular disease in the external layers of the 
tympanic membrane without involvement of the middle ear. 
There is so little material that it is impossible to describe 
any distinct form for the tuberculosis ; the descriptions by 
Stacke and Preysing (from Korner's clinic) differ widely, so 
that one is forced to assume two distinct types, a miliary, 
nodular form and one which appears as a granulation 
tumor. In Stacke's case ^ the tympanic membrane is de- 
scribed as presenting a bulging of its posterior half, and a 
yellowish discoloration, as though there were an exudate 
behind it. The surface was covered with split-pea-sized 
yellowish nodules, with small vessels radiating from their 
centers. The tympanic cavity contained no exudate. The 
redness of the tympanic membrane gradually increased, 

1 " Zeitschr. f. Ohr. ," x. ^ <i Arch. f. Ohr.," vol. xx, p. 270. 



TUBERCULOSIS OF THE EAR. 1 73 

and a yellowish ulcer formed in the inferior posterior seg- 
ment and led to a gradually increasing perforation. The 
examination failed to show the usual tubercular appear- 
ances. 

Preysing/ on the other hand, described a case of multi- 
ple tubercular tumors on the skull, in which the tympanic 
membrane was perforated in its inferior anterior segment 
and presented a flesh-colored, uniform mass, which eventu- 
ally proved to be tubercular granulation tissue. The author 
got the impression "that the tympanic membranes became 
infiltrated and broke up into tumor-like masses, but the 
external layer of the epidermis was always found to be 
intact." The typical form of the disease in the tympanic 
membrane is that which begins in the mucosa and ends in 
the destruction of the membrane. 

According to Habermann's histologic investigations, the 
disease begins with the formation of tubercular nodules ap- 
pearing on the tympanic membrane as small, yellowish ele- 
vations, which rapidly break down and lead to liquefaction 
necrosis of the entire membrane, although some cases are 
found in which the mucosa alone is involved, while in a 
few others the substantia propria also shares in the process. 
As the nodules break down, the integrity of the membrane is 
destroyed, so that we often see several distinct perforations 
at the same time, before the coalescence of the ulcers has 
resulted in the entire destruction of the membrane. Hence, 
the statement of various authors that tubercular perfora- 
tions preferably affect the inferior posterior segment of the 
tympanic membrane can not be accepted. 

A significant diagnostic point is the painless course of 
the disease ; while other inflammatory processes in the 
tympanic membrane are always associated with great pain, 
the symptom is almost always absent in tuberculosis in 
spite of the wide-spread inflammation and tissue destruc- 
tion. 

The nodule formation followed by disintegration is also 
characteristic of the disease in the other portions of the 
middle ear, but it is evident from the paucity of the reported 
cases that it is rarely possible to demonstrate it clinically. 
Usually, tuberculous disease of the middle ear presents 
itself in the guise of chronic otitis media. There is an 

1 " Zeitschr. f. Olir.," xxxii, p. 369. 



174 CHRONIC INFECTIOUS DISEASES. 

abundant discharge of a seropurulent secretion, which may- 
be more or less offensive. As the result of the breaking- 
down of the caseous nodules, the mucous membrane pre- 
sents an ulcerated appearance. Granulations and polypi 
are not present, as a rule. 

As we have said in connection with the perforation of 
the tympanic membrane, the course of the disease is usu- 
ally painless, but, on the other hand, it is characterized by 
rapid impairment of the hearing. This is due to the 
extensive infiltration, which spares neither the walls of the 
middle ear nor the immediate adjacent parts. One of the 
chief characteristics of the disease is the rapid development 
of caries, which soon destroys the ossicles and bony walls 
of the middle ear. Later, it involves the labyrinth and the 
mastoid process and leads to extensive tissue destruction, 
followed by grave functional disturbances. Eventually, 
the walls of the carotid artery and jugular vein may be 
eroded and fatal hemorrhage result, or the facial nerve is 
destroyed and paralysis ensues, or there may be total deaf- 
ness as the result of the destruction of the labyrinth. 
There is a constant danger of the process spreading to the 
interior of the skull, and thus producing fatal results. 
Either the carious bones undergo cheesy degeneration and 
are cast off as sequestra, or they merely show a gray or 
black discoloration. Marked granulation is usually absent. 
The entire bone crumbles, and it is often possible to remove 
large sequestra with the forceps. The operator is often 
surprised to see how deep the destruction has gone, espe- 
cially in children, often without any external signs ; not 
rarely it is possible to remove the entire bony wall as far as 
the middle or posterior fossa, so that a large portion of the 
interior of the skull is laid bare. Necrotic portions of 
bone from the labyrinth or the posterior wall of the audi- 
tory meatus are occasionally discharged through the ear. 
In neglected cases we often find behind the ear a bone 
fistula that continues to discharge for many years. 



LUPUS. 

Lupus of the mucous membranes of the upper air- 
passages may be primary or secondary to lupus of the ex- 
ternal skin. The primary form appears most frequently in 
the nose, although in recent years cases of primary disease 



LUPUS. 175 

in the pillars of the fauces, base of the tongue, and larynx 
have also been reported. . But the secondary form is far 
more frequent ; it coexists with lupus of the external skin, 
being communicated to the interior of the nose, the upper 
lip, or the external lip, especially the alse ; or, from the 
skin surrounding the mouth, to the mucous membrane of 
the cheeks, the palate, the pharynx, and the larynx. 

The chief characteristic of the disease is its painless 
course, which explains why the primary lupus eruptions 
on the mucous membranes usually escape observation, 
and the patient does not present himself for treatment 
until he is made aware of his malady by functional disturb- 
ances or by beginning deformity. This is abundantly 
proved by the systematic rhinoscopic and laryngoscopic 
examination of all cases of lupus of the external skin, for, 
according to Chiari and Riehl's ^ statistics, the larynx was 
involved in 6 out of 68 cases of lupus of the skin — i. e., in 
8.8^ ; while in former years, when an examination was 
made only Avhen demanded by the subjective symptoms of 
the patient, only 6 out of 725 cases, or o.^fc, were found 
to present this complication. 

Lupus of the mucous membrane presents the character- 
istic reddish-brown nodules, as large as the head of a pin, 
slightly excoriated or covered with silvery epithelial scales 
which run together and form extensive, slightly elevated 
infiltrations, or even grow into larger masses of a distinct 
papillomatous appearance. As in the external skin, the 
lesions show a marked tendency to break down, and the 
resulting scars lend to the diseased areas their well-known 
appearance. " Occasionally, the disintegration of contigu- 
ous infiltrated areas leads to the production of deep ulcers, 
which, owing to successive granulations, fail to heal, and 
are followed by the formation of irregular, glandular masses 
of hypertrophic and disintegrated granulations, traversed 
by bands of cicatricial tissue " (Chiari and Riehl). In 
spite of the active ulceration there is little tendency on the 
part of the ulcers to attack the deeper structures, and the 
bony skeleton of the nose and the cartilaginous structure 
of the larynx, excepting the epiglottis, are not as a rule 
involved ; on the other hand, the destruction of the cartil- 
aginous septum is a frequent, not to say regular, phenom- 

^ " Vierteljahrsschr. f. Dermat. u. Sj'ph.," 1882. 



1/6 CHRONIC INFECTIOUS DISEASES. 

enon. The scars show a tendency to contract, and this 
produces stenosis at certain points on the entrance to the 
nose, on the isthmus of the fauces, on the entrance of the 
larynx, and on the vocal cords. 

As regards lupus of the nose, it is found most frequently 
in the vestibule, and spreads from there to the septum, to 
the floor and lateral walls, and to the turbinated bodies. 
The external nose appears swollen at the tip and about the 
alse, and shows deformities corresponding to the cutaneous 
destruction, for the cartilaginous and fibrous portion of the 
septum may be destroyed without the exterior of the nose 
being attacked by the disease. The nose becomes swollen 
and drops forward, the tip coming nearer the upper lip. The 
most striking deformity is seen in the septum ; at first, 
while any tissue remains of the dividing wall, it appears 
on inspection to surround a huge perforation ; but later, 
when this slender remnant of tissue disappears and the 
nose loses its support, it is converted into a mere pendu- 
lous mass ; finally the ulceration attacks the remaining tis- 
sues of the nose, or the formation of cicatrices leads to 
further distortions and deformities. 

The cartilaginous septum occasionally presents a form 
of lupus described by the French as " lupus pseudo- 
polypeux."! It often appears isolated, without any coex- 
istent lesion in the external skin, but without a reservation 
we can not accept this as a special form of the disease, as 
there appears to be good reason to include it among the 
tuberculomata. 

Lupus of the mucous membrane preferably attacks the 
uvula, the pillars of the fauces, the posterior and lateral 
pharyngeal walls, and especially the base of the tongue, 
whence the disease may spread to the epiglottis and to the 
larynx. In fact, the epiglottis is the point of election, and, 
according to Chiari and Riehl, escaped in only 3 out of 
38 cases. Next in order of frequency follow the epiglottic 
folds, and last the vocal cords. It has been stated that 
the ulcers show no tendency to involve the cartilage 
(Kaposi, 2 however, as against this generally accepted view, 
mentions a case of complicated laryngeal perichondritis 
and chondritis), with the sole exception of the epiglottis, 

^ Cotnp. Simon in " Rev. de lar., d'ot. ," etc., 1895, No. 17. 
2" Lehrb.," 4th edit., p. 776. 



LEPROSY. 177 

the cartilaginous matrix of which falls an easy prey to the 
ulcerative process. 

The papillomatous granulations or cicatricial adhesions 
occasionally lead to laryngeal stenosis which may demand 
tracheotomy. Lupus of the vocal cords produces disturb- 
ances in the voice. On the whole, however, the course of 
the disease, especially in the initial stages, presents no 
symptoms, and the patients are remarkably free from pain. 

Lupus of the external ear differs in nowise from that of 
the external skin, and needs no special description. 



2. LEPROSY. 

Although leprosy is not endemic in our part of the 
world, an accurate knowledge of its nature is nevertheless 
necessary, as we not rarely meet with sporadic cases, espe- 
cially in the large cities where there are many foreigners. 
We find it stated in the latest descriptions of the malady 
that the mucous membranes of the upper air-passages, as 
well as the external skin, are a favorite seat of the disease, 
so much so, in fact, that the peculiar raucous voice pro- 
duced by laryngeal involvement has been regarded as 
absolutely typical of leprosy. Even at the present day 
there are so many more reports of leprosy of the larynx 
and pharynx than of nasal leprosy that after reading the 
usual text-books of the special literature one might get the 
impression that there is no typical clinical picture of nasal 
leprosy. The alterations that take place in the external 
tissues of the nose are well known, but the various descrip- 
tions of leprosy of the interior of the nose differ widely. 
It was customary to speak of epistaxis, " obstructive 
catarrh," perforation of the septum, and the development 
of ozena ^ as characteristic of the disease ; and some 
authors describe a diffuse swelling of the entire mucous 
membrane, with the formation of nodes, which later became 
ulcerated on the surface. Until recent years opinions 
diverged in regard to whether the disease extended to the 
cartilaginous and bony skeleton. Virchow's ^ proposition 

1 Jeanselur et Laurens, Soc. med. des Hopit. u. Lepra-Confer. , Berlin, 
1897. Joseph, "Berlin, klin. Wochen.," 1896, No. 25. " Zwillinger und 
Laufer, " Wien. med. Wochen.," 1888, Nos. 26 and 27. "Journal of 
Laryng.," 1888, No. i (M. Mackenzie). 

2 Geschwulste 11, p. 520. 

12 



1/8 CHRONIC INFECTIOUS DISEASES. 

was that "true perforation of the septum and depression 
of the bridge of the nose do not occur." This statement 
is not borne out by chnical experience. Although it is 
probably true that these destructions are not due directly 
to leprous disease of the cartilage and bones, yet necrosis, 
such as follows all ulcerative or inflammatory diseases of 
the nasal mucous membrane, undoubtedly does occur, as 
the mucosa plays a very important part in the nutrition of 
the skeleton of the nose, and even to some extent replaces 
the periosteum. 

In recent years the study of the pathogenesis of leprosy 
has produced a number of new theories in which the nasal 
alterations play an important role. The question was dis- 
cussed at some length in the Leprosy Convention held in 
Berlin in 1887, and since that time opinions in regard to 
the significance, frequency, and time of appearance of the 
nasal disease have undergone a marked change. 

In the older literature we frequently see it stated that the 
nose becomes involved later than the larynx and pharynx, 
and it was believed that the nasal disease was secondary to 
the pharyngeal process, although this theory is in direct 
opposition with the assumption that leprosy is an infectious 
disease which does not spread by continuity, but by the 
extension through the lymph-channels of the leprous infil- 
trate to all parts of the skin and mucous membrane. 

We now know that the nose is frequently attacked before 
the deeper portions of the air-passages, or may even be the 
only seat of the disease. Indeed, according to Gliick's ^ 
statistics, the percentage of nasal leprosy is greater than that 
of leprosy of the larynx and pharynx. Again, opinions 
differ as to whether the process in the mucous membrane 
is secondary to the cutaneous eruption or is to be consid- 
ered as going hand in hand with it, as it was believed that 
the mucous membrane was not involved in the leprous 
process until a later stage of the disease had been reached. 
At the present time, however, there is a general conviction 
that the process in the mucous membrane is a concomitant 
of the cutaneous disease, or even precedes it. After Gliick 
had published his percentage of 89.19 in a series of 33 
cases, Lima and de Mello found the frequency of early 
appearance of leprosy in the nose to be 95.83^, and 

1 Berl. Lepraconfer., 1897, i, i. Abth., pp. 19, 20. 



LEPROSY. 1 79 

thereby placed leprosy of the nose in its proper light. The 
question was finally solved when it was pointed out that in 
most cases the first effects of the infection were to be found in 
the nose, and that the nasal secretions of lepers constituted 
the most important factor in the spread of the disease. 

Sticker 1 in a careful examination of 153 lepers "failed 
to find distinct anatomic changes in the nose in only 13 
cases," and of these 13 there were 9 whose nasal secretions 
contained numerous bacilli of leprosy, thus affording an- 
other strong argument in favor of the view we have just 
stated, which is that of Sticker and of some others. We find 
a similar difference of opinion in regard to tuberculosis 01 
the nasal mucous membrane, which has been found very 
much more frequently since its appearance was demon- 
strated clinically ; it now plays a considerable part in the 
pathology of the nose, and is universally regarded as the 
result of direct infection. In both cases the divergence is 
explained by our advance in the knowledge of nasal dis- 
eases, as, owing to the polymorphous nature of the interior 
of the nose, early alterations are not very characteristic, 
and are merely classed under the head of chronic catarrh. 
When the disease has progressed so far that the changes 
are clearly visible in the skeleton and outer covering of the 
nose, the diagnosis becomes extremely easy, but the analy- 
sis of the changes becomes more and more difficult as the 
disease progresses, and the clinical picture becomes more 
and more complicated. 

As an example of the clinical picture seen in the early 
stages of leprosy I may mention a case which I had occa- 
sion to examine in the medical clinic of Professor Cursch- 
mann. It agrees so perfectly with the descriptions given 
by Gliick, Zwillinger, and Laufer of the earliest appear- 
ances in nasal leprosy that I will give it in lieu of a general 
description : 

A man, thirty-six years old, who had lived in Brazil 
since his sixth year, developed signs of anesthetic leprosy 
during the last three years, and during the last six months 
patches and diffuse infiltrations appeared on the skin, evi- 
dently the beginnings of a tubercular leprosy. The patient 
did not complain of subjective symptoms in the upper 
passages ; there was neither epistaxis nor nasal obstruc- 

1 Berl. Lej^raconfer., 1897, i, I. Abth., p. 99, and 11, p. 55. 



l80 CHRONIC INFECTIOUS DISEASES. 

tion. There was a diffuse infiltration in the mucous mem- 
brane of the septum ; the surface was smooth. As the 
result of the swelling in the middle of the right lateral 
wall of the nose there was a horizontal furrow, which at first 
sight looked like a deviation, while on the left side the 
hypertrophy was uniform. The mucous membrane over the 
turbinates was slightly hyperemic. The spongy tissue of the 
inferior turbinate was tense and swollen, returning to nor- 
mal on the application of cocain, showing that these parts 
were not as yet involved in the leprous infiltration. The 
vibrissas were preserved, the epithelium intact except in a 
small spot about the size of a split pea, situated in the pre- 
viously mentioned furrow in the septum, at the boundary 
between the cartilaginous and bony portions. This area 
presented the appearance of a superficial ulcer, with smooth 
edges, not raised above the level of the surrounding mucous 
membrane. The secretion of the nose was mucopurulent 
and moderately abundant in both halves of the nose ; the 
right side showed a greater tendency to the formation of 
crusts than the left, but the secretions did not possess any 
other characteristics of ozena. Thus, while the appearances 
of the interior of the nose were comparatively unimportant 
and not at all characteristic, the postrhinoscopic image pre- 
sented very conspicuous signs of the disease. Here there 
was also a diffuse infiltration of the mucous membrane of 
the septum and of the upper margin of the choanae, but, 
in addition, there were elevations about the size of a pea, 
with broad bases. These elevations were spotted, of a 
shiny yellowish color, corresponding to the whitish colora- 
tion of the nasal mucous membrane described by Lima and 
de Mello. The process did not extend beyond the poste- 
rior nares. 

The leprous nature of these alterations was abundantly 
proved by the finding of innumerable leprosy bacilli, partly 
in clumps, partly in chains, or in the form of leprosy cells ; 
and even in sections taken from the extirpated mucous 
membrane of the septum bacilli were found in large numbers. 

Falling of the vibrissae, which usually occurs late, was 
not observed in my case. There were no disturbances of 
sensibility in the nose. The sense of smell was somewhat 
impaired, although the patient himself did not observe it, 
and the examination with strongly odoriferous substances 
was difficult, as the man had lived in the primeval forests 



since his sixth year, and was, therefore, unacquainted with 
the odors of any of them. In a series of 13 cases, Gliick 
did not find much alteration in the sense of smell ; the 
sensibility of the mucous membrane was reduced in 3 cases 
out of 6. Epistaxis is an almost constant early symptom 
of nasal leprosy, but in my case it had not occurred. As 
a rule, the mucous membranes are dry, and there is a ten- 
dency to crust formation, so that the picture of ozena is 
simulated. If the infiltration extends more deeply, and 
especially if it attacks the turbinated bones, obstruction 
of the nose and consequent interference with respiration 
result. The tendency of the nodes to break down is espe- 
cially characteristic of the disease in the nasal mucous 
membrane, and in a short time ulcers develop in every part 
of the nasal cavity. As in the case of tuberculomata, 
septum perforations may be produced in the cartilage by 
the leprous infiltration. Lima and de Mello,i who give an 
excellent description of nasal leprosy, emphasize the pre- 
dilection of the nodes and ulcers for the turbinated bodies, 
" which may be atrophied and porous, or partly or totally 
destroyed, so that scarcely a trace of them remains " 
(Gluck). Defects have also been found in the other bones 
of the nasal skeleton, the vomer, the nasal bones, and the 
nasal spine ; however, they are not to be regarded as due to 
leprosy, but rather as the expression of a disturbance in the 
nutrition of the mucous membrane leading to atrophy and 
caries of the bones. 

In the pharynx leprosy affects principally the pillars of 
the fauces, the uvula, and to some extent the tonsils and 
the hard palate. Ulceration is said to be particularly apt 
to occur in the postnasal space. The fauces and the uvula 
become the seat of slightly elevated infiltrations, grayish- 
white or bluish in appearance, which undergo ulceration 
and cicatrization and lead to the formation of adhesions, 
particularly of the uvula. Perforations of the hard 
palate are mentioned by Zwillinger and Laufer, although 
Gliick finds no confirmation of the statement in the litera- 
ture or in his own cases. It is somewhat remarkable that 
Bergmann frequently found the posterior laryngeal wall 
intact when the other parts were affected with leprosy, and 
this is confirmed by Gliick, although the latter adds that he 

1 " Monatsch. f. prakt. Dermat.," vol. vr, 1887, No. 13 and I4. 



1 82 CHRONIC INFECTIOUS DISEASES. 

often found characteristic changes in this structure when 
the alterations in the mouth and nose were quite incon- 
siderable. 

In the larynx the epiglottis is the commonest and earliest 
seat of leprosy. " It becomes uniformly hypertrophied 
and studded with nodules, and presents a characteristic 
form and position, being markedly displaced backward and 
more or less compressed from side to side " (Bergengrun).^ 
" In severe grades of the disease the cartilage has a plump 
appearance ; the lateral margins of the glottis are uniformly 
thickened where they merge into the aryepiglottic folds. 
In severer grades, where the uniform hypertrophy extends 
below the ventricular bands and involves the posterior laryn- 
geal wall, the lumen becomes circular in outline ; and, 
finally, in the severest grades the nodules on the thickened 
ventricular bands and the enormously hypertrophied pos- 
terior laryngeal wall reduce the lumen of the larynx to an 
orifice no larger than a lead-pencil, and completely obstruct 
the view of the deeper portions." ^ Both the ventricular 
bands and the vocal cords participate in the nodule forma- 
tion and in the general hypertrophy, and even the subglot- 
tic mucous membrane is often markedly thickened. As 
the result of these changes, the voice becomes rough and 
hoarse ; in the later stages laryngeal stenosis makes its 
appearance, and sometimes during the night produces at- 
tacks of suffocation, so that the leprous wards are con- 
stantly filled with the blowing, gurgling, and whistling 
noises of the occupants (Bergengriin). "The flat and 
comparatively extensive ulcers which form in the infiltrated 
and nodular portions of the larynx show a marked ten- 
dency to undergo cicatrization, and, as a result, not only 
is the mucous membrane sometimes shrunken and de- 
formed, but even the cartilages maybe reduced in size " 
(Gliick). The cartilages of the larynx are never attacked 
alone, but the perichondrium almost regularly shows 
marked infiltration, and the bacilli may invade the cartilage 
from above (Neisser and Gliick). Little is known as to the 
sensibility of the diseased mucous membrane in the larynx 
and pharynx. A few observers refer to the ease with 
which a laryngeal examination can be made, and attribute 
it to anesthesia of the parts. 

^ " Arch. f. Laryng.," vol. TI. 

2 Schrotter, " Vorles. iiber Kehlkopf krankh.," 1892, p. 170. 



GLANDERS. 1 83 

In the external ear, characteristic changes, consisting in 
infiltration and nodule formation on the lobe, appear almost 
regularly in leprosy, but there is little mention in the litera- 
ture of involvement of the organ of hearing. Extension of 
the leprous infiltration to the tubes may lead to tubular 
catarrh. Lima and de Mello ^ examined the ears of 48 
lepers. They never found any alterations in the auditory 
meatus. In some cases the tympanic membrane was 
thickened, of a dull whitish color resembling " a fibrous 
plate," and "immovable during Valsalva's experiment." 
" There are adhesions in the wall of the tympanic cavity or 
between the ossicles." Other changes, consisting in anom- 
ahes of position and in convexity, are not leprous in char- 
acter. In one case perforation of the tympanic membrane 
occurred ; it was due to purulent otitis media. 



3. MALLEUS HUMIDUS. GLANDERS. 

Glanders is a disease of domestic animals, usually trans- 
mitted to man by the horse. The infection is carried by the 
malleus bacillus, which is contained in the secretion of the 
ulcers, especially in the nose, and gains entrance to the 
human organism through the skin or mucous membranes. 
The mucous membranes of the upper air-passages always 
share in the morbid process and present the characteristic 
miliary nodules, which later undergo ulceration. The 
breaking-down of neighboring nodules results in the for- 
mation of large ulcers, the floors of which are covered 
with a foul, sanguineous secretion. The ulcers show a 
marked tendency to invade deeper structures and occasion 
great tissue destruction. 

Clinically we distinguish a chronic and an acute form. 
Chronic nasal glanders, according to Koranyi,^ is ushered 
in by a feeling of fullness in the nose, a dry cold in the 
head, a feeling of heat in the throat, rough voice, cough, 
and, finally, by a mucous secretion, sparingly streaked with 
blood. Dry, blackish crusts are later expelled from the 
nose, and the mucous membrane underneath is seen to be 
swollen and ulcerated. Although the destructiv^e process 
is slower than in the acute form, in the end the amount of 

1 " Mon. f. prakt. Derm.," 1887, p. 650. 
- Nothnagel, vol. v. Part 5, p. 73. 



1 84 CHRONIC INFECTIOUS DISEASES. 

tissue destroyed is quite as great. The acute form may- 
occur either immediately after an infection or during the 
course of a chronic attack. It is accompanied by a cutaneous 
eruption, which spreads to the mucous membrane ; often it 
reminds one of variola, appearing first in the form of red 
patches, which later are replaced by pustules (Koranyi). 
By extension of the ulcers which result from the breaking- 
down of the infiltrate large areas are destroyed ; in the 
nose the septum becomes perforated, in the larynx the car- 
tilaginous structure is destroyed. The voice is rough or 
hoarse as the result of erosion of the vocal cords ; in the 
larynx the edema accompanying the ulceration sometimes 
leads to stenosis. 

The disease attacks the nasal bones, and these, as well 
as the skin covering them, are destroyed. The accessory 
cavities of the nose are also involv^ed. In Weichselbaum's ^ 
case masses of pus were found at the autopsy in the antrum 
of Highmore and in the frontal sinuses, and the mucous 
membrane was covered with numerous confluent yellow 
infiltrations. Occasionally, the disease attacks the cartil- 
aginous orifices of the tubes. The prognosis of nasal glan- 
ders is fatal, both in the chronic and in the acute form, 
while in chronic glanders of the skin cicatrization of the 
ulcers and arrest of the malady have occasionally been 
observed. 



4. FOOT-AND-MOUTH DISEASE. (THRUSH; 
STOMATITIS APHTHOSA EPIDEMICAj 

The mode of transmission of foot-and-mouth disease 
from animal to man has been extensively investigated in 
recent years. Although the disease almost exclusively 
concerns the digestive tract, if we disregard the constitu- 
tional phenomena to which it gives rise, it deserves to be 
mentioned in this connection, as it has also occasionally 
been observed on the mucous membrane of the nose, of the 
pharynx, and of the larynx. Koranyi ^ has given us a de- 
tailed description of the disease ; Siegel, in various papers, 
has reported an epidemic and the bacteriologic examina- 
tions which it occasioned, and his results, while attacked 

1 "Wien. med. Wochen.," 1885, No. 22. 

2 Nothnagel's, " Spec. Path. u. Therap.," v. Part 5. 



ANTHRAX ACTINOMYCOSIS. I 8 5 

by some, are confirmed by Bussenius,i who agrees with 
Siegel in regarding a smooth, ovoid bacillus as the common 
cause of stomatitis in man and of foot-and-mouth disease 
in cattle. The typical lesions consist of blebs, which rap- 
idly collapse and leave an ulcer, the floor of which is 
covered with a milky white exudate, while the edges are 
raised, dark red, and irregular in outline. The lesions are 
found on the tongue, gums, and palate, and occasionally 
also on the pharynx, and especially on the/r^^ border of the 
epiglottis. In the case reported by Bussenius large ulcers 
were found at the autopsy over the right arytenoid cartilage 
and on the epiglottis. According to Siegel, ^ the disease is 
often followed by "catarrh of the tubes," which "in chil- 
dren is usually purulent." Further details concerning this 
complication are wanting, but it is probably to be regarded 
as a suppuration from the middle ear. 



5. ANTHRAX. 

In the form of anthrax known as ragpickers' disease, or 
pulmonary anthrax, which is produced by the inhalation 
of dust containing the spores of anthrax, and which is usu- 
ally ushered in by a chill, we find, according to Koranyi, 
who quotes H. Eppinger in support of his statement, " the 
nasal mucous membrane swollen, suffused with blood, 
and the seat of small carbuncle-like formations ; the 
mucous membrane of the pharynx red and swollen, the 
tonsils covered with a diphtheroid membrane, the epiglottis 
red in color and hypertrophied." 



6. ACTINOMYCOSIS. 

Infection with actinomyces occurs usually in the mouth 
and oral pharynx by the wounding of the mucous mem- 
brane with spicules of grain, and is then followed by the 
well-known infection of the jaw and the submaxillary region. 
In rare cases actinomycosis extends to the larynx (Mund- 
ler^ and Berard^). There is in all cases a board-like infil- 

1 "Arch. f. Laryng.," VI, 1897. 2 "Arch. f. Laniyg.," Ill, p. j8i. 

3 " Beitr. zurklin. Chir.," 1892. 

* "Lyon m6d.," 1895, April 21 ; see in " Semon's Centralb.," X[i,p. 320. 



1 86 CHRONIC INFECTIOUS DISEASES. 

tration of the outer tissues of the neck, which in Berard's 
cases formed a rigid collar embracing the entire middle por- 
tion of the neck and rendering mov^ement of the head im- 
possible. The larynx, the pharynx, the thyroid gland, and 
the large vessels and nerves were found embedded in a 
mass of infiltrated tissue. Later, as a result of softening of 
the infiltration, pustules are formed, through which the 
characteristic yellow nodules are discharged. 

In other cases the disease manifests itself in the forma- 
tion of tumors on the thyroid cartilage and interior of the 
larynx ; Stork ^ saw a tumor which involved the aryepi- 
glottic fold, the arytenoid fold, and the epiglottic pharyn- 
geal region of one-half of the larynx, and cites a similar 
case observed by Illich. 



7. RABIES (LYSSA). 

The clinical picture of rabies in man is characterized by 
symptoms of irritation in the sensory and motor nerves, 
their intensity depending on the course of the disease. The 
hyperesthesia of the olfactory nerve finds expression in hal- 
lucinations of smell, that of the trigeminus in attacks of 
sneezing, both of which phenomena are observed in the pro- 
dromal stage of the disease. The full development of the 
disease is characterized by respiratory cramp, erroneously 
designated spasm of the glottis, which involves all the mus- 
cles of respiration. It is not even definitely known whether 
a so-called spasm of the glottis — that is to say, a closure of 
the glottis — occurs ; in Pitt's case,^ where a laryngoscopic 
examination was made during the attack, the glottis was 
found to be gaping, as a result (according to Semon) of 
violent irritation of the respiratory center causing contrac- 
tion of the crico-arytenoideus posticus, the respiratory mus- 
cle of the larynx, and thereby effecting abduction of the vocal 
cords. Lori also examined a patient during an inspiratory 
spasm, and was unable to demonstrate any participation of 
the laryngeal muscles. 

The implication of the auditory sphere manifests itself in 
a hyperesthesia of the auditory nerve. 

1 Nothnagel's " Spec. Path. u. Therap.," vol. xiii, Th. ii, Abth., I, 2d 
vol., p. 169. 

2 Compare " Semon's Centralb. ," i, p. 251. 



TRICHINOSIS. 187 



8. TRICHINOSIS. 

Navratil ^ and Friedreich ^ each reported a case of laryn- 
geal paralysis, the result of trichinosis. The left vocal 
cord was immovable midway between phonation and respi- 
ration, and there was, in addition, a paralysis of the con- 
strictors of the pharynx. 

1 "Berlin, klin. Wochen.," 1876, p. 292. 

2 Quoted by Lori, " Die Veranderungen des Rachens," etc., p. 237. 



VIII. DISEASES OF THE KIDNEY. 



The complications which may appear in the course of 
nephritis in the upper air-passages consist in edema, hem- 
orrhage, and general nutritive disturbance in the mucous 
membranes. 

Edema occurs in the pharynx and larynx, especially in 
portions where the submucosa is well developed. Edema- 
tous swellings are, therefore, found chiefly in the uvula, 
the posterior faucial pillars, and on the lateral pharyngeal 
wall ; in the larynx they are constantly found on the ary- 
epiglottic folds, either on one or on both sides, and in their 
extension to other portions of the organ obey the general 
principles governing the spread of edema in the larynx. 

According to Fauvel and Schr6tter,i edema of the larynx 
is often the first sign of nephritis, and therefore enjoys a 
certain distinction from a diagnostic point of view. It must, 
however, be a very rare occurrence ; at least, Morell Mac- 
kenzie 2 failed to find a single case, although he made a 
laryngoscopic examination of 200 nephritic patients with 
this end in view. Lori ^ reports two cases observed by 
himself The edema is passive, being entirely due to ven- 
ous stasis, and is occasionally observed on the posterior 
tracheal wall. Appearances simulating laryngeal stenosis 
are seen in uremic conditions, for uremic asthma may 
resemble bronchial asthma if expiration is prolonged, or 
may simulate laryngeal stenosis if inspiration is prolonged 
(E. Wagner *). But the fact that it always appears period- 
ically in individuals with normal respiration establishes the 
differential diagnosis. I once had occasion to make a laryn- 
goscopic examination of this kind two days before the out- 
break of a fatal uremia ; in spite of the negative appearance 
of the laryngeal image, the apparent laryngeal stenosis had 
led the attending physician to perform tracheotomy. 

^ " Vorlesungen," p. 92, 1st edit. 

2 " Lehrb. libers, von Semon," I, p. 374. ^ Loc. ciU, p. 80. 

* Ziemssen's " Handbuch," ix, 3d edit., p. 70. 
188 



It may be mentioned that uremic apliasia ^ has been 
observed in combination with unilateral palsies, due solely 
to serous infiltration of the brain-substance. 

A more familiar and more frequent occurrence than edema 
is hemorrhage, due partly to the increase in blood pressure 
and partly to the changes in the blood-vessels which are so 
frequent in chronic interstitial nephritis. In addition to the 
epistaxis, which is often severe, there may be lesser hemor- 
rhages in the pharynx and larynx ; they occur a short time 
before the appearance of the uremia. As in all diseases of 
the circulatory apparatus, we find nutritive disturbances in 
the mucous membrane, manifesting themselves as atrophic 
catarrh ; and if at the same time there are similar hemor- 
rhages, there usually results the form of nephritis and 
laryngitis which is sometimes described as the chronic 
hemorrhagic variety. In the case of uremia which I have 
just mentioned I found a remarkable appearance of the mu- 
cous membrane ; there was a marked dryness throughout 
the upper air-passages, although there could not be said to 
be any atrophic alterations in the nose or in any other part. 
The nose, as well as the larynx, was covered with minute 
dark-colored coagula, the remains of hemorrhages in the 
nose and throat. These coagula were so completely dried 
out that they were expelled in the form of dust with the 
respiratory air-current, which, on account of the dyspnea, 
was very violent. Tiirck ^ describes a case of sudden 
hoarseness and pain in the larynx, in which the organ was 
much inflamed ; at the autopsy the mucous membrane of 
the interior of the larynx was found to be red in color and 
covered here and there with patches of delicate croupous 
membrane. Lori ^ also observed a case, which he described 
as " diphtheritic," in the course of a chronic parencJiyinatous 
nephritis : " The lesions consisted in grayish-white crusts 
the size of a pea, embedded in the mucous membrane of the 
tonsils and of the left arytenoid cartilage, and in a similar 
more extensive alteration on the upper surface of the epi- 
glottis, which disappeared in a few days." This clinical 
picture hardly justifies the diagnosis of " diphtheritis." 

To Dieulafoye and his followers we owe a detailed descrip- 
tion of nephritic aural diseases, a few cases of which are also 

^ Senator, Nothnagel's " Handbuch Nierenkrankh.," p. 69 ; and Jaeckel, 
Berliner Dissert., 1884. 

2 " Klinik," pp. 177 and 178, Case 20. ^ x^^. cit., p. 82. 



190 THE KIDNEY. 

found in the older literature. Morf^ has contributed a 
comprehensive treatise, in which, in addition to three of 
his own cases, he discusses twenty-two others collected 
from the literature. He admits, however, that his explana- 
tion of the clinical appearances and the nature of the dis- 
ease is somewhat faulty, as he classes into one group 
nephritic disturbances due to pathologic processes in the 
ear, demonstrable microscopically or by functional exami- 
nation, and into another group cases in which it was not 
possible to account for the functional disturbances by any 
pathologic changes in the tissues. 

It must be admitted that aural disturbances are rare in 
nephritis. The statistics reported are small as regards the 
number of cases, and not very reliable on account of the 
limited amount of material on which they are based. It 
can not be determined whether any one form of nephritis 
possesses any special power of producing disease in the ear, 
but it would appear that chronic diffuse nephritis is more 
apt to do so than any other ; in a few cases aural disease 
was observed in chronic nephritis after intermittent fever 
and in scarlatinal nephritis. Clinical and anatomic investi- 
gations have shown that aural disturbances may occur in 
the course of nephritis as the result of the general edema, 
and in uremia after hemorrhages. Tinnitus aurium and 
loss of hearing also occur as the result of secondary dis- 
ease of the blood-vessels ; and, lastly, it may be mentioned 
that a certain influence on the development and course of 
purulent otitis media has been ascribed to nephritis. ^ 

Hemorrhages in the middle ear have been described by 
Schwartze,^ Buck,* and Trautmann.^ They manifest 
themselves either as suffusions in the middle ear or as 
hemorrhages in the mucous membrane ; the latter are ex- 
plained by Trautmann as the result of diapedesis. The 
diagnosis can be made by the bluish-red coloration of the 
tympanic membrane seen in the otoscopic image, while the 
subjective symptoms vary according as the hemorrhage 
was sudden or gradual, the tinnitus aurium being accord- 
ingly rapid or more gradual in its onset. 

As examples of the other form of impaired hearing due 

1 " Zeitschr. f. Ohr.," xxx., H. 4. 

2 " Die Krankh. des Ohres," pp. 185-188. 

2 " Arch. f. Ohr.," iv, p. 12. * " Arch. f. Ohr.," vii, p. 301. 

^ " Arch. f. Ohr.," xiv, pp. 91, 92. 



EAR. 191 

to general edema we may mention one case of Rosenstein^ 
and two cases of Morf,^ in which, in the course of a chronic 
nephritis after intermittent fever (twice), and in acute 
nephritis (once), a gradually increasing loss of hearing 
was observed culminating in total deafness. Here the 
tuning-fork test for air- or bone-conduction was almost 
or quite negative (Morf). In both cases the hearing was 
occasionally completely restored during the course of the 
nephritis, and such temporary improvement was always 
accompanied by improvement in the general condition and 
subsidence of the edema. Rosenstein's case is the only 
one in which an autopsy was held ; it was entirely negative. 
The fact that the loss of hearing progresses pari passu 
with the development of the edema, the periodic complete 
return of the power of hearing, and its final disappearance, 
in the case of acute nephritis without any local treatment 
of the ear, suggests the explanation advanced by Rosen- 
stein for his own case : that we have to deal with edema of 
the roots and trunk of the auditory nerve, and that the 
variations in the power of hearing are directly dependent 
on the increase or decrease of the edematous infiltration. 

A similar explanation applies to the disturbance observed 
in chronic uremia due to serous infiltration of the brain- 
substance. It is impossible to find any anatomic changes 
to account for the tinnitus and loss of hearing, nor can the 
exact location of the lesion be determined by means of the 
functional test. 

Many cases of tinnitus aurium and defective hearing 
occurring in the course of nephritis are undoubtedly refer- 
able to secondary disease of the blood-vessels, and belong 
in the same category with the phenomena observed in 
arteriosclerosis and valvular lesions. 

Finally, we have to consider suppurations in the middle 
ear, which are considered by some authors — among them 
Morf, Voss,^ and Haug — as caused, or at least influenced, 
by nephritis. 

There have been observed in the course of nephritis 
acute and chronic catarrhal, acute and chronic purulent, 
and hemorrhagic inflammations of the middle ear, but the 
nephritic character of the aural disease has not been defi- 

^ " Nierenkrankheiten," 4th edit., 1S94, p. 260. 
2 " Zeitschr. f. Ohr.," pp. 324 and 32S. 
2 "Arch. f. Ohr.," xxvi, p. 233. 



192 THE KIDNEY. 

nitely established. In proof of its dependence on nephritis 
certain postmortem appearances have been cited, consist- 
ing chiefly in hyperplasia of the submucous tissue in the 
middle ear, interpreted as an edema ; but such a finding 
is not in the least remarkable in view of the long duration 
of the cases under discussion (Gurovitsch ^ and Moos 2), 
and is often found quite independent of nephritis. Morf 
claims that purulent processes in the middle ear have a 
remarkable tendency to produce necrotic osteitis and a 
carious liquefaction of the bony walls of the air spaces in 
the temporal bone, but his claim finds little support in the 
literature, and the autopsy in one case of purulent otitis 
media after nephritis, which suggests the possibility of a 
casual relation between nephritis and otitis (I mean that of 
Gurovitsch), did not show any marked disease of the bones. 
Although the suppuration had existed for three months, 
there was no more than a seropurulent fluid in the mastoid 
cells. Thus it is seen that there is not sufficient proof to 
warrant the assumption of a special nephritic purulent otitis. 
It would appear, however, from certain reliable observa- 
tions, that the course of chronic otitis media may be influ- 
enced by a coexistent nephritis, any exacerbation of the 
renal trouble being accompanied by increase in the purulent 
flow, and vice versa. This interdependence is clearly shown 
in Gurovitsch's case, and it also appears, from observations 
by Voss, that the dyscrasia which accompanies nephritis is 
capable of aggravating an existing aural trouble in diabetes. 
The value of Voss' observations is somewhat impaired by 
the fact that they refer to a case of scarlatinal nephritis, 
since the development of both diseases — the nephritis and 
the otitis — depends on an intoxication, and therefore a 
coincident increase in both sets of symptoms may be ex- 
plained by an increase in the common virus. Haug^ men- 
tions a case of scarlatinal nephritis and otitis in which open- 
ing of the mastoid process was followed by improvement in 
the nephritic symptoms, while a subsequent exacerbation 
occurred in consequence of retention of pus due to granu- 
lations ; this observation should at least incite us to more 
critical investigation of the Hterature in this respect. 

1 " Berlin, klin. Wochen," 1880, No. 42. 

2 " Schwartze's Handb.," i, 538. ^ Loc. cit., p. 188. 



IX. DISEASES OF THE SKIN AND OF THE 
SEXUAL ORGANS. 



U DISEASES OF THE SKIN, 

The vestibule of the nose, as far as the ph'ca vestibuli, 
is lined with epidermis, and is therefore attacked by the 
same diseases that affect the external integument. The 
most frequent disease affecting the vestibule, and with it 
the upper lips, is eczema, which leads to the same appear- 
ances in these regions as on the external skin. The nose 
may be either the primary or the secondary seat of eczema, 
for in scrofulous children, the subjects of chronic rhinitis, 
we frequently observe the development of eczema, which, 
as a result of the continual irritation of the nasal secretions, 
tends to spread more and more and to invade the face, 
while, conversely, general eczema of the external skin 
sometimes spreads to the vestibule of the nose. 

We could mention a large number of skin diseases 
which extend into the vestibule of the nose ; but as their 
diagnosis and treatment are the same here as on the exter- 
nal skin, with the exception of infectious processes such as 
lupus and syphilis, which are treated of elsewhere, they 
need not be discussed in detail in this place. There are 
certain diseases of the skin which in rare cases also lead to 
alterations in t/ie miicons membranes of the upper air-passages 
analogous to the general process, although presenting cer- 
tain differences in their appearance. Thus, there is a 
greater tendency to loss of epithelium and ulceration, due 
no doubt to the maceration which occurs in the mucous 
membrane as the result of the secretion, the moisture, and 
the warmth of the air-passages, so that, speaking generally, 
the mucous membrane shows defects and ulcerated surfaces, 
whereas the diseased epidermis of the skin remains as a 
protective covering in the form of scales and crusts. 

For this reason a disease in the mucous membrane will 
in a few hours undergo certain peculiar changes and lose 
n 193 



194 THE SKIN AND THE SEXUAL ORGANS. 

the characteristic appearance of the same disease in the 
skin. The vesicle-formation of herpes and the formation 
of larger blebs characteristic of pemphigus are rarely seen, 
as the loosened epithelial cells are rapidly cast off, and thus 
the typical appearance of the disease is destroyed ; in im- 
petigo and erythema the superficial infiltration rapidly 
undergoes necrotic changes and is replaced by ulcers, so 
that all these diseases present the uniform picture of an 
exudative process followed by ulceration, and Seifert ^ 
and Schech ^ accordingly include them under one clinical 
picture, which, when it occurs in the larynx, is designated 
by the latter as exudative laryngitis. 

Owing to the scarcity of complications in the mucous 
membranes of the upper air-passages, we are reduced to a 
few reports from other countries,^ which would be even 
scantier were it not for the fact that affections of the oral 
cavity, particularly of the hard and soft palates, are often 
included among diseases of the pharynx. Among the 
skin diseases observed in the nose, the pharynx, and the 
larynx are herpes, urticaria, lichen, impetigo, and erythema. 
I decline to include miliaria (Lori *) and eczema of the 
throat (M. Schmidt •'^), because I do not regard either of 
these affections as anything more than an acute inflamma- 
tion of the mucous membrane accompanied with unusual 
redness and swelling of the gland ducts, in no sense to be 
compared with eczema or miliaria of the external skin. In 
a general way, the seats of predilection of these diseases 
may be said to be the uvula, the posterior and lateral 
laryngeal walls, the base of the tongue, the epiglottis, and 
the upper margin of the larynx ; it is quite possible that a 
predisposing factor for this particular localization is to be 
sought in the mechanical irritation to which these parts are 
particularly exposed during the ingestion of food. Herpetic 
eruptions, like those illustrated in Krieg's " Atlas," ^ occur 
in the pharynx and larynx, usually in combination with 
herpes labialis ; occasionally, the eruption in these parts is 

^ " Heym. Handb. der Laryng. u. Rhin.," I, p. 448. 

2 " Miinch. med. Wochen.," 1898, No. 26. 

3 I shall not quote the reported cases ; they have been given by Schech, 
" Miinch. med. Wochen.," 1898, No. 26; by'Seifert, " Heym. Handb. der 
Laryng.," i, p. 448, and by Klemperer, " Heym. Handb.," I, p. 1286. 

* " Die durch anderweitige Erkrankung bedingten Veranderungen," etc., 
p. 86. 5 << Krankh. der ob. Luftwege," 2d edit., p. 531. 

6 " Atlas." Plate XXXV. 



DISEASES OF THE SKIN. 1 95 

secondary to that on the lips. As the vesicles are deprived 
of their covering they frequently coalesce and lead to the 
ulceration of larger areas, as pointed out by Stepanow,i thus 
complicating the differential diagnosis from syphilis and 
diphtheria. Schrotter ^ says he has never seen herpetic vesi- 
cles converted into ulcers. According to him, the membrane 
which in a short time replaces the vesicle separates without 
leaving any alterations behind. The literature is particularly 
rich in cases of pemphigus in the upper air-passage, where 
pemphigus vulgaris, pemphigus foliaceus, and pemphigus 
vegetans have been observed. As an example of pemphigus 
vulgaris we may mention Schrotter's case,^ in which there 
were periodic eruptions in the larynx, varying in extent 
and analogous to those on the rest of the body : "Thus 
the clear, transparent vesicle would appear on the epiglottis, 
and after a few hours the contents would become turbid, 
and finally yellow. The vesicle itself gradually con- 
tracted and collapsed more and more, and finally lay in 
folds on the surface, like a croupous membrane. The sur- 
rounding area was not specially inflamed." Thost ^ gives 
the following description of chronic pemphigus foliaceus 
with implication of the nasal, laryngeal, and pharyngeal 
mucous membrane. The diseased portions of the mucous 
membrane "became the seat of isolated whitish patches, 
irregular in shape, and varying in size from a split pea to a 
quarter of a dollar. These patches consisted of loosened 
epidermis, which appeared like a crumpled piece of paper 
or hung in shreds, and in the nose and postnasal space 
became dry and scaly, while the snow-white color changed 
to a dirty grayish-brown, or even reddish tint, if any blood 
was present. The surrounding portion of the mucous mem- 
brane showed marked reddening. The white epithelial 
covering was easily torn, and could be removed from the 
rete Malpighii without difficulty, exposing the red papillary 
layer, which bled when touched with a probe." Accord- 
ing to Thost, the process heals without cicatrization in 
a short time, often within twenty-four hours, although 
Krieg, in his case of recurring pemphigus foliaceus, of 
which he gives several very good illustrations,"* speaks of 
the cicatricial appearance of the palatal mucous membrane. 

1 " Mon. f. Ohr.," 1885, p. 237. 

2 " Vorlesungen iiber die Krankh. des Kehlkopfes," 1st edit., p. 62. 

3 " Mon. f. Ohr.," 1896, p. 165. * " Atlas," Plate XXXVI. 



196 THE SKIN AND THE SEXUAL ORGANS. 

Neumann,^ in describing pemphigus vegetans, points out 
that in an analysis of 41 cases the primary seat of the dis- 
ease was frequently found in the pharynx and larynx, and 
once in the nose.^ In regard to diseases of the mucous 
membranes in erythema exudativum multiforme, we have 
cases reported by Lanz ^ and Schoetz.^ Du Mesnil and 
Marx ^ give an example of impetigo herpetiformis 
(Uffinger ^) and one of lichen ruber acuminatus, while 
hchen ruber planus is described by Marx. ^ Occasionally, 
the mucous membrane of the upper air-passages partici- 
pates in urticarial eruptions, especially in the chronic 
relapsing form, where, as described by Cala,^ the mucous 
membrane of the larynx may gradually become swollen 
and lead to asphyxia. 

Diseases of the skin frequently spread from the external 
skin to the external ear and auditory meatus. Eczema is 
the most important, although herpes, impetigo, pityriasis, 
psoriasis, and pruritus also occur. It is, of course, of the 
greatest importance in the treatment to decide what form of 
otitis externa eczematosa is present, and whether there is 
suppuration of the middle ear w^th perforation of the mem- 
brane. As the diagnosis is often rendered difficult by the 
presence of a marked purulent secretion due to the eczema, 
and by the impossibility of inspecting the drum membrane 
on account of the great swelling of the walls of the meatus, 
it is well to bear in mind the symptoms which establish a 
diagnosis of purulent otitis media, without the macroscopic 
demonstration of perforation of the tympanic membrane. If 
the pus contains mucus, it is a sign that the middle ear is 
the source of the discharge ; while pulsation of the pus in 
the external meatus and the presence of bubbles in the dis- 
charge are positive proofs of the existence of a perforation. 
Except in cases of moist eczema or of other processes asso- 
ciated with transudation, when the epidermic layer of the 
tympanic membrane becomes thickened and the membrane 
itself chronically inflamed, these skin diseases do not invade 
the ear-drum or the middle ear. 

1 " Wien. klin. Wochen.," 1898, No. 8. 

2 Riegel, " Wien. med. Wochen.," 1882, p. 274. 

3 " Berlin, klin. Wochen.," 1886, No. 41. * Ibid., 1889, No. 27. 
5" Arch. f. Derm. u. Syph.," 1889, xxi. 

«" Semen's Centralbl.," XI, p. 3S6. Lukasiewicz, " Arch. f. Derm. u. 
Syph.," 1896, vol. XXXIV. 

" Wiirzburger Dissertation. * " La Semaine Med.," 1889, S. 346. 



SEXUAL ORGANS AND UPPER AIR-PASSAGES. 1 97 

2. THE INFLUENCE OF NORMAL OR PATHO- 
LOGICALLY ALTERED SEXUAL FUNCTIONS 
ON THE UPPER AIR-PASSAGES. 

RELATION OF THE SEXUAL ORGANS TO THE UPPER AIR- 
PASSAGES. 

Our knowledge of the relations existing between the 
male, and especially the female, sexual functions and the 
upper air-passages has recently been enriched by a number 
of important additions. 

Even the earlier literature contains a few contributions on 
the subject of vicarious menstruation through the nose, 
swelling of the nose and coryza during the menses or during 
the sexual act, and epistaxis as a consequence of masturba- 
tion. It has, however, been reserved to the most recent times 
(Hack) to reduce these relations to a system, ^ although it 
seems to me that Fliess occasionally exaggerates, in his 
otherwise noteworthy and on the whole scientific work on 
the relations between the nose and the female sexual organs. 
Such relations exist even under physiologic conditions at 
the time of puberty and during coJiabitation, and in the 
female during nienstmation, the menopmise, and pregnancy. 

The most important pathologic condition is found in 
masturbation, although some influence is to be ascribed to 
gynecologic diseases, especially chronic endometritis and 
displacement of the uterus. In the last category of cases, 
however, it is difficult to tell to what extent the primary 
disease, or rather the hysteric condition of the patient 
which frequently accompanies it, can be held responsible 
for the sequels, which usually manifest themselves in the 
form of a nasal reflex neurosis. Examining the symptoms 
observed in the upper air-passages under the influence of 
sexual disease, we find that they consist in the main of 
phenomena referable to the vascular system, such as Jiyper- 
eniia, siuelling, exudations, and hemorrhages in the mucous 
membrane. 

The vasomotor system of the entire body is intimately 
connected with the sexual functions. Hence it is easy to 
understand that in any universal determination affecting the 
entire body the specialized vascular system of the nose 

^ John Mackenzie, "Johns Hopkins IIosp. Bull.," Baltimore, Jan., 1S98. 



igiS THE SKIN AND THE SEXUAL ORGANS. 

should be more extensively implicated than other systems 
in the body. We must bear in mind the abundant blood 
supply of the nasal fossae, and especially the erectile tissue 
embedded in the mucous membrane of certain portions 
of the turbinate bodies and of the septum. The pres- 
ence of this tissue, which in its structure is analogous to 
the erectile tissue in the sexual organs, suggests the idea 
that it bears a certain relation to the sexual processes in the 
body, and it has been stated that the swelling in the nose 
is analogous to that which takes place in the clitoris and 
in the penis. There are, however, two considerations which 
tend to disprove the existence of such a relation : In the 
first place, the nasal phenomena must be regarded as ex- 
ceptional ; and, in the second place, while the anatomic 
structure of the erectile tissue in the nose in a general 
way resembles that found in the genitalia in the arrange- 
ment of smaller cavities on the surface and larger ones 
in the deeper tissues, it presents one important difference 
in the fact that the individual cavities possess muscular 
walls, which, under the influence of the sphenopalatine 
ganglion, may cause its contraction or dilatation. As we 
have previously explained, the position of the tissue in the 
nose shows that it is concerned solely with respiration ; if 
it had any connection with the sexual function, it would 
be hard to understand why it is found in the respiratory 
portion of the nose and not in the olfactory. 

We therefore consider the congestion which takes place in 
the nose as a mere local expression of a universal determi- 
nation in a region particularly rich in blood-vessels. The 
mildest grades correspond to the hyperemia that accompa- 
nies any simple swelling and usually leads to periodic ob- 
struction of one or both nares ; the secretion of the swollen 
mucous membrane is increased, and in the end may even go 
on to hemorrhage. These hemorrhages appear to be usually 
diffuse, like carious hemorrhages in other parts of the body ; 
they do not lead to tissue-destruction, and are usually de- 
rived from the turbinate bodies, although the septum may 
also be the source of a habitual epistaxis. In the sexual 
life of the woman such conditions, which, in consequence 
of the congestion, are generally associated with headache, 
are observed in the beginning, or even as prodromal symp- 
toms, of menstruation ; but they may also have a compensa- 
tory function when the menstruation is abnormal, and finally 



SEXUAL ORGANS AND UPPER AIR-PASSAGES. 1 99 

may appear after the establishment of the menopause at the 
regular menstrual intervals. 

We should call attention also to the observation of 
various authors that these phenomena may also appear in 
a diseased nasal mucous membrane, for Mackenzie states 
that in ozena the odor becomes more intense and the secre- 
tion more abundant during the menstrual period. 

The so-called " erysipele catameniale " may also be in- 
cluded among the vasomotor reflex neuroses referable to 
the genital organs. It manifests itself in redness and swell- 
ing of the tissues about the external nose and of the organ 
itself. 

There are certain reflex relations between definite regions 
of the nasal mucous membrane and the female genitalia. 
Although they may appear very obscure, and in Fliess' ^ 
description baffle comprehension, their existence, proved by 
a series of well-known facts, can not be disregarded. As 
long ago as 1884 we find in Kupper's ^ paper a warning 
against the use of the galvanocautery on the erectile tissue 
of the nose in pregnant women, on the ground that he twice 
saw it followed by abortion, and Schech goes so far as to 
say that pregnancy is an absolute contraindication to the 
use of the galvanocautery. ^ Fliess has shown by an exten- 
sive series of investigations in the gynecologic clinic of the 
University of Berlin that there are certain points on the 
anterior extremity of the middle and inferior turbinate 
bodies and on the tubercle of the septum — designated by 
him genital areas — through which some influence can be 
exercised on pathologic conditions in the female sexual 
apparatus. By cocainizing the "genital areas" the pains 
which accompany or follow the menstrual flow can be re- 
lieved and labor pains can be reduced to a minimum, while 
by cauterizing these areas permanent cure of dysmenor- 
rhea may be achieved. 

The pharynx, and especially the larynx, as well as the 
nose, may be the seat of congestions which can only be 
interpreted as derived from the genitalia. As during 
puberty, at the time of the so-called change of voice, 
the mucous membranes of the upper air-passages are sub- 
ject to congestions, which are often the cause of the voice 
becoming easily tired, similar hyperemic conditions occur 

1 Loc. cit. 2.< Deutsclie med. Woclien.," 1884, No. 51. 

3 Schech, 5th ed., p. 289. 



200 THE SKIN AND THE SEXUAL ORGANS. 

during menstruation, during pregnancy, and in certain 
uterine affections, which from their effect on the singing 
voice are generally much better appreciated by singers 
than by physicians. Ruault ^ observed hemorrhages from 
the vocal cords accompanying the menstrual flow. 

Sensory disturbances in the form of paresthesia and 
hyperesthesia, depending on sexual influences, have been 
described in all the mucous membranes of the upper air- 
passages ; they manifest themselves in dryness of the 
throat, a feeling as of a foreign body, and desire to cough. 
They may be due partly to the hyperemia of these parts, 
but more particularly to the irritable condition which char- 
acterizes the entire nervous system at these periods. Irrita- 
tion of the olfactory nerves, in the form of hyperosmia and 
parosmia, is sometimes observed. In speaking of asthmatic 
attacks as produced by disturbances in the genital region 
we approach perilously near the boundary-line between 
conditions due to sexual disturbances and coexistent hys- 
teric phenomena, a boundary which is difficult to define in 
practice. 

Finally, we must mention those phenomena which mani- 
fest themselves during the sexual development of the biody 
in functional disturbances of the voice. The most famliar 
of these is the change which occurs at puberty. It is 
a purely physiologic process, due to the increased develop- 
ment of the larynx, which occurs at this time and neces- 
sitates the adaptation of the muscles to the increased 
size of the organ. In most cases the change from the 
childish treble to the adult register takes place during the 
time of puberty without any marked disturbances, provid- 
ing the voice, which at this time becomes easily hoarse and 
fatigued, is not unduly strained. Occasionally a slight 
hyperemia is observed in the vocal cords, but there is no 
abnormality in the movements of the larynx. The change 
of voice may be considered pathologic only when it lasts 
for some time and when the voice after puberty retains a 
childish or uncertain tone, without the character of a defi- 
nite register. In the male this consists in a high, piping 
voice, which often changes suddenly to a deeper tone for a 
few words under the influence of emotion ; or, if it changes 
to a higher register, gives out altogether ; while in the 

^ See " Semon's Centralbl.," vi, p. 323. 



SEXUAL ORGANS AND THE EARS. 20I 

young- girl, as pointed out by Storck, it becomes abnor- 
mally deep and rough. 

In the male this falsetto voice, which must be regarded 
as the effect of an abnormal prolongation of the voice- 
changing period, is designated as the eunuch's voice (Four- 
nier) ; it may last for only a short time after puberty, or 
may, as shown by numerous cases, persist a greater length 
of time as a more or less ridiculous vocal anomaly. Al- 
though the condition causes the patient a good deal of 
annoyance, it, as a rule, readily yields to treatment. 

There is no alteration of the laryngeal image, either in 
the form of redness or anomalies of motion of the vocal 
cords, notwithstanding Fournier's attempt to construct a 
series of clinical pictures. This is what we should expect 
if we remember that the eunuch's voice is the expression 
of a disturbance in the coordination of the laryngeal mus- 
cles, consisting in a failure of the mechanism to adapt itself 
to the dimensions of the fully developed larynx, and the per- 
sistence of a false register. By a judicious series of exer- 
cises, consisting mainly in training the voice to adhere to a 
lower key, a cure can usually be effected in a few sittings. 

The vocal changes which accompany old age, and con- 
sist in roughness or shrillness, may be due to ossification 
of the laryngeal skeleton and to consequent changes in the 
vibrations. 



RELATIONS BETWEEN THE SEXUAL ORGANS AND THE 
EARS. 

Stepanow,! Eitelberg, and Gradenigo ^ have observed 
cases in which hemorrhages from the ears occurred either 
vicariously or coincidently with menstruation. In most of 
the cases the organ of hearing had been affected with 
chronic catarrh or chronic suppuration, and the power of 
hearing was more or less reduced during the intervals be- 
tween the attacks. The hemorrhages from the ear usually 
occurred on the day before the appearance of menstruation, 
and, in the cases of menstrual anomalies, on the days on 
w^hich the menses should have appeared. They were usu- 
ally confined to one side, the same ear being affected in 
every attack. The amount of blood varied from two drops 

1 "Mon. f. Ohr.," 1885, No. Ii. 

2 " Arch. f. Ohr.," vol. xxviii, p. 82. 



202 THE SKIN AND THE SEXUAL ORGANS. 

to quantities greater than that of a normal menstrual flow. 
The hemorrhage is usually heralded by a kind of aura, con- 
sisting in headache, slight vertigo, and tinnitus aurium. 
The region of the hemorrhage appears to be the tympanic 
membrane and the external meatus, especially the mouths 
of the cerumen glands on the posterior and upper walls. 
After the hemorrhage has subsided, nothing abnormal is 
usually found except a slight hyperemia of the gland ducts 
referred to, though in Eitelberg's case the tympanic mem- 
brane was the seat of petechiae. 

We may mention that certain observers have reported the 
occurrence of hemorrhages at the time of menstruation in 
cases of perforating chronic otitis media, associated with 
granulations. These cases are too obscure to be regarded 
as vicarious hemorrhages. The same statement applies to a 
few doubtful cases in which hemorrhage is said to have 
occurred in the labyrinth at the appearance of the menses. 
(Jacobson,^ Koll-.) 

The changes in the auditory function during these vicari- 
ous hemorrhages from the ear are interesting. During the 
hemorrhage there is a uniform hyperesthesia of the auditory 
nerve for all registers, and a diminution in the electric reac- 
tion. The sensibility is reported in some cases as increased ; 
in others, as aboHshed. At the time of menstruation tinni- 
tus aurium is often observed ; it is probably due to the 
hyperemia accompanying the flow. 

Masturbation is said to aggravate an existing aural affec- 
tion and to exaggerate a chronic catarrh or suppuration. It 
is sometimes given as the cause of subjective noises, which 
are probably an expression of abnormal irritability of the 
vasomotor centers. 

The connection between pregnancy and the pucrpcruun 
and chronic catarrh of the middle ear is so generally recog- 
nized among the laity that it is given as the cause of deaf- 
ness -in an abnormally large number of the cases, but the 
value of the patient's statement in this respect is much 
reduced when we find that in most cases it is possible to 
demonstrate objective alterations in the ear which can not 
possibly be referred to that physiologic condition of the 
female organism. If, as I believe we are justified in doing, 
we exclude all cases of obstinate catarrh of the middle ear, 

1 " Arch. f. Ohr. ," xxi, p. 2S0. 2 " Arch. f. Ohr.," xxv, p. 88. 



GONORRHEA. 203 

the cause of which can be demonstrated in diseases of the 
nose and pharynx, and cases of former purulent otitis media 
with remaining alterations in the middle ear and on the drum 
membrane, there remain only the forms of so-called chronic 
catarrhal otitis media without alteration of any kind in the 
tympanic membrane, and cases attended with tinnitus 
aurium. Bezold ^ has found that among 190 women suffer- 
ing from this form of middle ear catarrh, ly.gfo referred 
the beginning, or at least a subsequent aggravation of 
their deafness, to pregnancy or the puerperium. In some 
cases there was a successive deterioration in the auditory 
power at each pregnancy. 

These auditory disturbances are no doubt closely related 
to the disturbances in the circulation to which the female 
organism is subject during the time of menstruation and 
pregnancy, and to the anemic conditions which follow the 
puerperal period. Thus we find that, analogous to the in- 
fluence exerted by diseases of the circulatory system on the 
ear, anemia and hyperemia constitute important etiologic 
factors in the production of functional disturbances of the 
auditory organ. As the deafness and tinnitus aurium which 
occur during menstruation may be regarded as the result of 
the general determination, and as representing hyperemic 
conditions in the deeper portions of the organ of hearing, it 
is equally plausible that the chronic venous stasis and in- 
creased irritability of the entire nervous apparatus which 
characterize pregnancy should be capable of producing dis- 
turbances in the auditory function. Concerning emboli in 
the ear during the puerperium, and pyemic disease of the 
ear after puerperal fever, we have very few contributions. 



3. GONORRHEA. 

The occurrence of gonorrhea in the nose and in the 
pharyngeal cavity is now beyond dispute, and the many 
assertions made to the contrary in former times are 
wholly without foundation. These depended partly on 
theoretic speculation in regard to the mode of infection 
of mucous membrane covered with squamous and cylin- 
dric epithelium in gonorrhea. The rarity of nasal infection 
in comparison to the frequency of gonorrhea is to be 

i"Arch. f. Olir.," vol. XXV, p. 225. 



204 THE SKIN AND THE SEXUAL ORGANS. 

attributed to the fact that the vestibule of the nose is hned 
with epidermis. Infection is usually due to uncleanliness 
in the use of handkerchiefs ; the skin, however, opposes a 
natural barrier to the invasion of the virus. We find not 
only in the new-born, in connection with gonorrheal con- 
junctivitis, where infection takes place during birth, but 
also in adults, as the result of direct transmission to the 
nasal mucous membrane from other sources, a purulent 
rhinitis as the result of this mode of infection, the nature of 
which is proved by the bacteriologic demonstration of the 
gonococci (Miller i). I once had occasion to observe two 
cases of purulent rhinitis in the secretions of which typical 
gonococci were found within the pus-cells, occurring in 
two children of the same family, aged four and six respec- 
tively, who lived amid poverty-stricken and uncleanly sur- 
roundings and shared the bed of their gonorrheal mother. 

In this connection it is interesting to note the possibility 
of gonorrhea being conveyed to the oral mucous mem- 
brane of infants (Rosinski 2), where it manifests itself in 
the form of a whitish exudate ; Cuttler ^ and Salzmann * 
each report a case of gonorrheal ulcerative stomatitis, the 
result of an infection contracted by coitus per os. 

Occasionally arthritis may be localized in the articulations 
of the larynx and produce symptoms similar to those 
which occur in acute articular rheumatism. Liebermann ^ 
and Simpson ^ describe a disease of the crico-arytenoid 
articulation which appeared in connection with swellings in 
other joints after an acute gonorrhea. In one of these 
cases the left arytenoid cartilage was the seat of redness 
and swelling, most marked over the articulation, and 
this on sounding was found to be fluctuating. The left 
vocal cord failed in adduction. At the same time there 
were aphonia and violent pain in the region of the larynx, 
increased by pressure on the thyroid cartilage. Gradu- 
ally the voice improved, and after six weeks the swell- 
ing disappeared, although the vocal cord continued slug- 

1 Stork, " Nothnagel's Handb.," xni, 1st half, p. 86. 

2 "Zeitschr. f. Gynak," 1891. 

^ See " Semon's Centralbl.," vi, p. 166. 

* Kraus, " Nothnagel's Handb.," XVI, I Th., I Abth. , p. 244. 

s From " Soc. med. des Hopit.," 1S73, p. 388, reprinted by Archam- 
bault, Th6se de Paris, 1886. 

"From "Med. Rec," July, 1S89, reprinted by Lacoarret, "Rev. d. 
Laryng.," 1891, p. 398. 



SYPHILIS. 205 

gish in its movements after the voice had almost re- 
gained its usual quality. In Simpson's case the swelling 
subsided more rapidly, but there also remained a sluggish- 
ness in the movements of the vocal cord on the affected 
side and in the region of the joint when the patient was 
discharged after eleven days. Lazarus^ has described a new 
variety of gonorrheal disease of the larynx on the strength 
of a case of bilateral paralysis of the crico-arytenoidei 
postici in gonorrheal arthritis. As no alterations could be 
demonstrated with the laryngoscope in the arytenoid car- 
tilages or in the mucous membrane of the interarytenoid 
space, and as there was neither tenderness nor pain in the 
cartilages of the larynx, the clinical picture of this form is 
clearly distinguished from that seen in the articular affec- 
tions just described, and we must agree with Lazarus — 
although he does not dwell on these points in the differ- 
ential diagnosis — in explaining his case as one oi gonorrheal 
neuritis, the occurrence of which finds ample confirmation 
in the investigations carried out by Leyden.^ 

The localization of gonorrheal disease in the ear has 
never been reported ; Flesch ^ believes that he once found 
gonococci in the pus derived from the middle ear of an 
infant. One of Fischel's * histories contains a note to the 
effect that, in a case of gonorrhea, tinnitus aurium was fol- 
lowed within twenty-four hours by complete bilateral deaf- 
ness, but it is of little value. 



.4. SYPHILIS, 

We are unable to devote to syphilis of the upper air-pas- 
sages the space which its importance and frequency demand. 
The subject is fully discussed in all text-books on syphilis 
and in many special essays,^ so that I shall refer only 
briefly to the most important points. 

Primary sores are found in the nose in the region of the 
vestibule, which is accessible to infection by the finger. 

1 " Arch. f. Laryng.," V, p. 232. 2 " Zeitschr. f. klin. Med.," 1S92. 

3 «< Berlin, klin. Wochen.," 1892, No. 48. 

* Fischel, " Prag. med. Wochen.," 1891, No. 11. 

5 Neumann," Syphilis," Nothnagel's " Spec. Path. u. Therap.," 1897, vol. 
XXIII. Lang, " Vorlesungen," 2d ed., 1895. Gerber, " Syphilis der Nase u. 
des Halses," "Berlin, bei Karger," 1895. Seifert, "Deutsche med. 
Wochen.," 1893, 42, 44, 45. 



206 THE SKIN AND THE SEXUAL ORGANS. 

They have been observed on the alse and on the septum, 
and deserve mention because they may obscure a diagnosis 
in two different ways. When the sore is situated on the 
inner surface of the alae and leads to marked swelling and 
redness of that region, there is at first, before the glands of 
the face and neck become enlarged and the induration sur- 
rounding the ulcer becomes apparent, a possibility of mis- 
taking it for furuncle ; and when the symptoms are fully 
developed, the lesion may be mistaken for a gumma. The 
secondary stage appears on the mucous membrane of the 
nose at the same time as on the external skin, but it occurs 
less frequently and presents fewer morphologic varieties. 
Erythema and papules are probably very rare on the mu- 
cous membrane, for opinions differ as to the possibility of 
their occurrence there ; they are somewhat more frequent 
in the vestibule and, according to some, on the floor of 
the nose and septum. Lang ^ depicts a vegetating papule 
situated on the boundary between the epidermis and car- 
tilaginous septum. One form of early syphilis in the nose 
is a peculiar catarrh, differing from acute catarrh by its 
insidious onset and by the character of the secretion, which 
is thick, though scanty. It may possibly be regarded as a 
specific erythema. The mild character of the symptoms 
and the fact that complete recovery takes place — for super- 
ficial ulcerations in the mucous membranes are very rare 
(Lang) — probably explain the scarcity of the reports about 
this form of catarrh. 

The most important manifestations of syphilis in the nose 
belong to the tertiary stage. Both the lesions themselves 
and the defects and cicatricial contractions which result 
after they heal often require local treatment. The heredi- 
tary forms resemble the tertiary in their course. 

It is well known that gummatous disease may appear 
under various forms and run a very different course in dif- 
ferent cases. The circumscribed tumor-like variety is rare 
in the nose ; when it does occur, it is most frequently local- 
ized on the epidermic and cartilaginous septum and on the 
alae. According to Koon, Manasse,^ and Kuttner,^ one 
ought to distinguish as a special form syphilitic granulo- 
mata, which, however, can not be differentiated from tuber- 
culomata either clinically or histologically, at least in those 

1 Loc. cit.. Fig. 56. 2 " Virch. Arch.," Bd, CXLVn, p. 32. 

3 " Arch. f. Lar. u. Rhin.," vn, 1898. 



SYPHILIS. 207 

cases in which it is impossible to find either tubercle bacilli 
or cheesy detritus in the tubercle. They differ from the 
ordinary gummatous tumors by the presence of a pedicle 
or a broad base and by their greater vitality, as they 
show no tendency to central necrosis, and only a slight 
tendency to superficial ulceration. Manasse regards them 
as simple connective-tissue tumors, originating in the sub- 
mucous connective tissue, and either pushing the epithe- 
lium before them or breaking through it. 

Gummatous infiltration with chronic inflammation lead- 
ing to hyperplasia of the mucous membrane is very com- 
mon, and manifests itself in the form of a hypertrophic 
rhinitis — the coryza neonatorum of hereditary syphilis. 
Sooner or later the process goes on to tumor formation, but 
before that event occurs the disease may attack the peri- 
chondrium and periosteum of the cartilages and bones 
of the nasal skeleton, and lay the foundation for necrosis of 
the cartilage and sequestration of the bone. Referring to 
such cases, in which sequestra were found under the hyper- 
trophic, intact mucous membrane, Sanger ^ and E. Frankel ^ 
make the statement that the bony framework of the nose 
may become diseased independently of the mucous mem- 
brane. Sanger distinguishes three forms of bone disease, 
which he calls exfoliated necrosis following suppurating 
processes, rarefying luetic osteitis, or caries sicca, and rare- 
fying and plastic osteitis. We also recognize a syphilitic 
chondritis in addition to perichondritis. As a result of all 
these processes we find the familiar defects in the soft parts 
and in the bones, producing the characteristic cicatricial 
contractions and distortions, and often leading to adhesions 
and stenosis. 

While any part of the bony skeleton may be attacked by 
the disease, the median and lateral walls manifest a peculiar 
predisposition. In the septum the bony portion is chiefly 
involved, and the vomer, as well as the perpendicular plate 
of the ethmoid bone, may be more or less completely 
destroyed by the necrosis. The situation of these defects 
is of significance in the differential diagnosis from tubercu- 
losis, which produces its ravages especially in the cartil- 
aginous septum ; although it not rarely happens that the 
syphilitic process involves the cartilaginous as well as the 

^ " Vierteljahrschr. f. Derm. u. Syph.," 1S77, pp. 89 and 90. 
2 " Virch. Arch.," 75. 



208 THE SKIN AND THE SEXUAL ORGANS. 

bony septum. We must take exception to the statement 
made by Schech^ that syphilis preferably attacks the ante- 
rior cartilaginous portion of the septum. The detection of 
a perforation of the septum is sometimes difficult when the 
mucous membrane is still in the hypertrophic stage, or if 
the sequestrum, as often happens, separates from the poste- 
rior extremity of the vomer. Next to the septum the 
turbinate bodies are the commonest seats of the disease, 
and are sometimes partly or completely destroyed. The 
floor of the nose becomes involved, and large perforations, 
heralded by swelling of the floor, occur in the hard palate 
and sometimes afford a view into the nose from the mouth, 
Lang mentions extension of the disease to the lamina crib- 
rosa, with following meningitis. Syphilitic caries of the 
ethmoid cells has been reported by Gerber, Lange, and 
Hellmann^. 

After a hypertrophic syphilitic rhinitis has passed through 
the stage of ulceration, the cicatricial contraction or the 
atrophy of the mucous membrane leads to a condition that 
is clinically known as atrophic rhinitis. Owing to its con- 
version into scar tissue, the loss of the ciliated columnar 
epithelium, the degeneration of the blood-vessels, and the 
disappearance of the glands and erectile tissue, the mucous 
membrane loses the power of performing its normal 
function ; the dried secretions accumulate in the widened 
cavities of the atrophic organ, undergo decomposition, and 
lead to the formation of crusts. The offensive odor with 
which the condition is associated has given rise to the 
unscientific and misleading term ozena syphilitica. It 
appears from the investigations of Zukerkandl^ that the 
mucous membrane of the accessor}^ cavities may also par- 
ticipate both in the hypertrophy and in the subsequent cica- 
tricial process. 

While crust formation and fetor are rarely absent in old 
cases of nasal syphilis, they may also be found in the 
earlier stages of a variety of diseases. Crust formation is 
observed in any form of ulceration, while fetor always 
accompanies necrosis of the bone and is constantly present 
in atrophic rhinitis. The tissue destruction that takes 
place in the course of syphilis in the skin and in the car- 
tilaginous and bony framework of the nose produces the 

1 " Die Krankh. der Mundhohle," etc., p. 311. 

2 "Arch. f. Lar. u. Rhin.," ni, p. 210. ^ " Anat. der Xase," vol. n. 



SYPHILIS. 209 

most extensive alterations, which only are not visible with 
the rhinoscope, but also leave an indelible mark of the 
disease on the external appearance of the patient. The 
well-known syphilitic nose is the terror of patients, and, 
with the exception of lupus, there is no other disease 
capable of producing such frightful disfigurement. The 
commonest deformity consists in the so-called '^saddle-nose,'' 
characterized by the sinking of the bridge of the nose and 
elevation of the tip, while* the flattening that accompanies 
it appears to increase the transverse diameter. The nose 
as a whole is reduced in size, which is explained by Neu- 
mann as a molecular atrOphy of the bone. Besides the ab- 
sence of the nasal septum, this deformity may be produced 
by various causes. Defects in the cartilaginous portion of 
the septum do not alter the shape of the nose, even when 
the vomer is destroyed. When, however, the upper ante- 
rior portion of the perpendicular plate of the ethmoid bone, 
the posterior support of the two nasal bones, is destroyed, 
the sinking of these bones, which is further increased by 
the cicatricial contraction, produces a marked change in 
the shape of the nose. There are, however, cases of 
saddle-nose in which no such coarse destructions of tis- 
sue are found, and several theories have been offered to 
explain their formation. According to Moldenhauer, 1 it is 
produced by a cicatricial contraction of the connective tis- 
sue that unites the cartilaginous and bony portions of the 
external nose, while Neumann ^ mentions two novel phys- 
ical factors, "the first of which consists in the loosening 
and partial destruction of the connections between the 
bony and cartilaginous structures, and the second in a 
difference of atmospheric pressure between the external air 
and that of the interior of the nose which accompanies 
every inspiration." "As long as the framework of the 
nose is intact and the musculature of the cartilaginous 
portion performs its functions, these two factors suffice to 
maintain the equilibrium during the decreased pressure 
which accompanies the inspiration. But as soon as these 
structures suffer a loss of integrity they are no longer 
capable of resisting the external pressure, and a sinking of 
the nose results in the direction of the increased external 
pressure." 

1 " Lehrb. der Nasenkrankh.," Leipzig, 1886. 

2 Nothnagel's "Spec. Path. u. Therap.," xxiii, p. 344. 
14 



2IO THE SKIN AND THE SEXUAL ORGANS. 

The destruction of the bony, cartilaginous, and epidermic 
portions of the septum produces a characteristic deformity 
of the profile, consisting in a depression of the nose, which, 
deprived of its posterior support, becomes a mere mass of 
flesh overhanging the nasal cavity, and, in obedience to the 
laws of gravity, approaches the upper lip. Various other 
deformities may be seen as the result of destruction of 
other parts of the bony or cartilaginous framework of the 
external nose, among which we may mention one that is 
particularly common in the hereditary forms of syphilis, and 
in which, in addition to the saddle-shape, there is a com- 
plete flattening of the nose by destruction of the alae and 
cartilages of the lateral walls, so that in profile the nose is 
not raised above the level of the face, and in the front view 
presents the appearance of two irregular, distorted open- 
ings, corresponding to the anterior nares, covered by a 
perforated plate of tissue. ^ 

The pharynx is a favorite seat of syphilis in all its forms. 
The primary chancre is found on the palatal tonsils, which 
are much swollen, dark blue in color, and frequently the 
seat of superficial ulceration, while the submaxillary and 
submental glands are at the same time greatly enlarged. 
Infection may take place in a variety of ways — by direct 
inoculation during improper practices, by eating with 
infected forks or spoons, and sometimes even by surgical 
instruments. It is important to mention that a chancre on 
the tonsil may be mistaken for diphtheric tonsillitis, tonsil- 
lary abscess, carcinoma or sarcoma of the tonsils, or for a 
gumma. The erythematous and papular eruptions which 
occur on the faucial pillars, on the tonsils, and on the soft 
palate are so well known that their description may here be 
omitted. 

They are never observed on the posterior laryngeal wall, 
but are occasionally seen in the postrhinoscopic image on 
the posterior surface of the uvula. 

Condylomata resembling papillomata are sometimes seen 
on the hard and soft palate, on the pillars of the fauces, 
and on the tonsils, in the form of pale gray nodular excres- 
cences. 

The tertiary forms of acquired syphilis and the various 
hereditary types produce marked alterations in the pharynx. 

^ Some instructive illustrations are found in Rang, loc. cit., Figs. 62-68. 



To begin with the tonsillar space, we may mention the 
gumma infiltrations, tumors, and ulcerations that are 
usually found associated with diseases in the nose and in 
the oral pharynx. The diagnosis in such cases presents no 
difificulties. It is more difficult when the nasopharynx 
alone is diseased. The symptoms complained of by the 
patient are very vague : headache, depression, lassitude, 
loss of appetite, and occasionally earache — nothing that 
might point to an exact diagnosis ; and the diseased focus 
may remain undiscovered until for some reason a postrhi- 
noscopic examination is made. We then find ulcerations 
in the roof of the pharynx, in the neighborhood of the 
choanae, and sometimes on the lateral pharyngeal wall, 
which are readily recognized as syphilitic ulcers by their 
irregular outline, sharp edges, and excavated floors cov- 
ered with yellowish secretions. The disease may invade 
the periosteum and the bone, or there may be from the 
beginning a syphilitic osteitis, ending in necrosis and ex- 
tensive destruction of the surrounding bony walls. If the 
disease is situated in the roof of the pharynx, part of the 
sphenoid bone, if on the posterior wall, parts of the cervi- 
cal vertebrae, especially the atlas and axis, may give way 
and cause large openings into the vertebral canal, or ulcer- 
ation and severe hemorrhage from the vertebral artery may 
occur. 

A gumma on the posterior surface of the soft palate 
generally results in perforation of that structure, usually 
just below its attachment to the palatal bone, and leads to 
various deformities, according to the size of the perfora- 
tion. If the tissue destruction is great, the soft palate is 
loosened from its attachment and drops down, so that if 
the perforation is situated in the middle line above the 
uvula, the latter may come in contact with the base of the 
tongue. In extensive ulcerations the entire uvula and large 
portions of the soft palate and faucial pillars may be de- 
stroyed ; and as the disease is not limited to the soft parts, 
the palatal bone itself is often perforated, so that it is pos- 
sible to obtain a view of the nose from below. 

The syphilitic alterations in the posterior and lateral 
walls of the pharynx deserve special attention, as they may 
be mistaken for follicular catarrh or for a chronic hypertro- 
phic catarrh of the plica salpingopharyngea (Neumann), if 
they appear in the nodular form or in the form of diffuse 



212 THE SKIN AND THE SEXUAL ORGANS. 

infiltrations. The true nature of the disease is easily recog- 
nized by its tendency to cause rapid destruction of tissue. 

Krecke^ once saw two hard, spherical granulation tumors, 
the size of a pigeon's egg, on the posterior wall of the 
pharynx, which showed no tendency to break down, and 
disappeared on the administration of potassium iodid. 
They probably belonged to the same category as the gran- 
ulation tumors described by Kuhn-Manasse. 

As has been stated, the tissue destructions that occur in 
the course of tertiary or hereditary syphilis are of the 
greatest importance, and their practical significance is 
accentuated by the subsequent cicatricial contractions and 
adhesions, which may lead to marked functional disturb- 
ances. While, on the one hand, destruction of the hard 
and soft palates produces changes in the voice and difficulty 
in swallowing by making it impossible to effect a closure 
of the posterior nares, the cicatricial contractions, on the 
other hand, frequently lead to stenoses in the nasal 
pharynx, which embarrass nasal respiration, and rarely to 
a stenosis in the deeper portions of the pharynx, which 
interferes with the ingestion of food. 

Tl;ie scar that follows the healing of a specific ulcer on the 
mucous membrane has the same radiate appearance char- 
acteristically seen in the external skin after the healing of 
syphilitic lesions. Where there is a solid foundation, as on 
the posterior pharyngeal wall, the mucous membrane has a 
tense, glistening appearance, resembling tendon, while in the 
neighborhood of the isthmus the scars lead to distortions of 
the soft tissues. The symmetry of the posterior nares is 
destroyed, the uvula is drawn to one side or rolled on itself, 
and the palatal ridges are distorted almost beyond recogni- 
tion. 

Neighboring areas in the mucous membranes are fre- 
quently the seat of cicatricial adhesions, which are due to 
the tendency of the lesions to produce contact ulcers on op- 
posed surfaces. Thus, we frequently see bands of adhesion 
uniting the posterior pharyngeal wall to the soft palate. 
The adhesion may be so extensive as to shut off the oral 
cavity completely from the postnasal space, or the adhesion 
may be only partial, leaving a chimney-like opening into the 
postnasal space, through which the secretions from the 

1 " Miinch. med. Wochen. ," 1894, No. 47. 



SYPHILIS. 213 

nose trickle down into the pharynx, as there is usually a 
coexistent chronic fetid rhinitis. These adhesions may be 
visible at the first glance on ordinary inspection, but some 
of them are more obscure, and require a postrhinoscopic or 
laryngoscopic examination for their detection. Among 
these we include the adhesions which are seen when the soft 
palate is only partly destroyed, and which take the form of 
a horizontal diaphragm-like membrane between the pos- 
terior surface of the soft palate, near its attachment to the 
palatal bone, and the posterior pharyngeal wall, or those 
which lead to the formation of adhesive bands in the post- 
nasal space between the roof of the pharynx and the swollen 
orifices of the Eustachian tubes, or between the latter and 
the margins of the choana; or the posterior pharyngeal wall. 
Both these forms of postsyphilitic alterations occasion great 
discomfort, the destructive variety interfering with nasal res- 
piration and lending a peculiar dead quaUty to the voice, 
while the cicatricial form, by involving the tubes, leads to 
certain disturbances in the hearing, to be discussed later. A 
rare form of adhesion is one which forms between the base 
of the tongue and the posterior pharyngeal wall. 

Synechia; between the soft palate and the posterior wall 
are of such frequent occurrence and give rise to such dis- 
tressing symptoms that they often require operative treat- 
ment. In view of the tendency of the two divided portions 
of an adhesion to reunite, and thus oppose a serious 
obstacle to the success of the operation, it may be well to 
discuss briefly the conditions which explain not only the 
original formation of the synechia, but also its tendency to 
recurrence. When the soft palate performs its normal 
functions, and when, in obedience to the laws of gravity, it 
retains its perpendicular position and moves with every act 
of deglutition and phonation, there is small danger of 
the opposing surfaces becoming adherent, even when they 
are the seat of ulcers, as the constant movement of the soft 
palate would loosen any adhesive bands as fast as they 
formed ; but when, on the contrary, the soft palate, as the 
result of deformity or the distortion of syphilitic scars, is 
brought nearer the posterior wall of the pharynx and loses 
its normal mobility, the conditions for the formation of an 
adhesion are proportionately more favorable. Neumann ^ 

^ Nothnagel's "Spec. Patli. u. Therap.," xxni, p. 320. 



214 THE SKIN AND THE SEXUAL ORGANS. 

has pointed out that " adhesions are especially liable to form 
when the faucial pillars are totally or partially destroyed, and 
when, owing to an antecedent syphilitic myositis, the palato- 
glossus, the palatopharyngeal, and the pterygo-, mylo-, 
glosso-, and buccolaryngeal muscles, as well as the middle 
constrictor of the pharynx, fail to act." 

The hoarseness of syphilis, under the name of " raiicego 
syphilitica," was formerly deemed of some importance by 
physicians, is still regarded among the laity as a frequent 
sign of an old infection. It is, therefore, surprising to 
learn from the statistics that syphilitic disease of the 
larynx is comparatively rare. Statistics based on dispen- 
sary work in diseases of the throat show a rather low per- 
centage of laryngeal syphilis. According to Schrotter,! 
8.7^ among 35,826 patients; according to Rosenberg,^ 
3.6^ (there were 58 cases of specific laryngeal disease 
among 16,000 patients in B. Frankel's polyclinic) ; while 
other authors give somewhat larger percentages, based on 
shorter series of cases. It might be thought that this 
conspicuous infrequency of the disease is due to the noto- 
rious indifference of the patients, and to the fact that many 
physicians do not feel called upon to devote any special 
attention to it, as it disappears under general antisyphilitic 
treatment, were it not for the fact that the investigations 
by syphilographers, made with a view to determining the 
laryngeal complications, have yielded similar results. The 
most reliable analysis is that made by Lewin,^ who, 
among 20,000 syphilitic subjects in his clinic, found 575 
cases, or 2.9^, of laryngeal diseases, 13^ of which were 
grave and ^y ^o comparatively mild. 

Secondary syphilis appears in the larynx in the form of 
erythematous and papular eruptions, going on to ulcera- 
tion ; while the tertiary stage, which often appears as early 
as one year after infection (Semond "*), is represented by 
gummatous disease, which may manifest itself as a small 
nodular syphilid, as a diffuse infiltration, or as a circum- 
scribed gumma. The symptom-complex of laryngeal 
syphilis further includes the ulcers due to the breaking- 
down of the gummatous tumors and to the perichondritis 

^ See Gerber's statistics, loc. cit., p. 44. 

^ " Krankh. der Mundhohle," etc., 1893 ; Karger, p. 306. 

* " Charite Ann.," vol. vi, p. 538. 

* " Centralbl. f. Laryng.," X, 203. 



SYPHILIS. 215 

which follows as the result of extension to the cartilages. 
Finally, we may regard as sequels the scar formations and 
the chronic infiltrations and contractions which remain and 
lead to permanent functional disturbances in the voice or 
to marked stenosis. 

The question whether we are justified in considering 
catarrhal disease of the laryngeal mucous membrane as an 
erythematous eruption is still undecided, in spite of 
Lewin's ^ paper advocating the recognition of such an 
erythema. For my part, I agree with that author, and 
believe that the condition usually designated as syphilitic 
catarrh is not a catarrh in the ordinary sense of the word 
and differs clinically from an ordinary catarrhal laryn- 
gitis. _ 

It is characterized by a peculiar, dark, bluish-red or 
brownish-red (Lewin) discoloration, which makes it appear 
in the laryngeal image like a peculiar, one might almost 
say specific, hyperemia, especially as it lacks swelling and 
increased secretion, the ordinary symptoms of catarrh of 
the mucous membrane. Although it has been so described 
by certain French authors, the red discoloration is not such 
as to justify the designation of roseola or macular syphilid, 
being diffuse rather than circumscribed. 

In some cases the erythema as we have just described it 
becomes covered with gray patches or rings elevated above 
the hyperemic mucous membrane (as illustrated by Schnitz- 
ler),2 resembling the mucous patches of the soft palate. 
Although they are also observed on the epiglottis and on 
the aryepiglottic folds, their favorite seat is on the vocal 
cords. The superficial layers of the epithelium very soon 
separate and the patches are converted into superficial 
ulcers. The occurrence of flat and of acuminate condy- 
lomata on the laryngeal mucous membrane has been de- 
scribed. The former are due to hyperplasia of the papillae, 
and appear as pale gray prominences with broad bases, 
slightly elevated above the mucous membrane, preferably 
situated on the free border of the vocal cords, on the epi- 
glottis, and on the aryepiglottic folds. They rather resem- 
ble papules or opalescent patches, and the old name of 
condylomata would perhaps best be discarded, especially in 
diseases of the mucous membrane. This applies still more 

1 " Charite Ann.," vol. VI. ^ "Atlas," PI. xil, I. 



2l6 THE SKIN AND THE SEXUAL ORGANS. 

to the so-called acuminate condylomata that have been 
described in the larynx, the existence of which, however, 
is denied by the majority of authors — Lewin, for instance, 
never saw a case of this kind. They can not be positively 
distinguished from the granulating edges of an ulcer, or 
even from connective-tissue tumors, such as fibromata, 
papillomata, and so on, as they do not yield to antisyphilitic 
treatment. 

Among tertiary lesions, as has been stated, we distin- 
guish the three forms of nodular syphilids, diffuse gumma- 
tous infiltration, and gummy tumor. 

The first of these manifests itself in the form of small 
nodules, varying from the size of a pinhead to that of a 
split pea, closely aggregated or even confluent. Lewin 
remarks that their covering of mucous membrane, which is 
at first normal, gradually assumes a yellowish discoloration 
as the process passes into ulceration. This form, which is 
also found on the palate and in the pharynx, maybe diffi- 
cult to diagnose from lupus or tuberculosis in the absence 
of evident signs of syphilis in other parts of the body. It 
is true that the nodules show less tendency to the scar for- 
mation which in lupus appears coincident with the forma- 
tion of ulcers, and the reaction in the surrounding areas is 
less marked, but these phenomena are all so variable that 
we are often driven to the test of antisyphilitic treatment. 
The subjective symptoms are of some diagnostic value, 
since syphilitic disease, as in the other mucous membranes 
of the upper air-passages, runs a painless course, while 
lupus, and especially tuberculosis, is associated with severe 
pain in the throat and with dysphagia. 

The diffuse infiltrations and the gummy tumors represent 
different expressions of the same gummatous disease. The 
former are the more frequent ; the latter, until recent times, 
were considered as very rare forms, although a hasty sur- 
vey of the last volume of Semon's " Centralblatt fiir Laryn- 
gologie " reveals a goodly number of cases. While the 
diffuse infiltrations preferably affect the epiglottis and the 
aryepiglottic folds, where they lead to a diffuse swelling, 
covered with healthy, smooth mucous membrane, the 
gummy tumors may be found in any part of the larynx in 
the form of circumscribed spherical bulgings. They also 
occur on the ventricular bands and below the vocal cords, 
are frequently isolated, and may, as long as the mucous 



SYPHILIS. 217 

membrane remains intact, be confounded with incipient 
malignant tumors, such as carcinoma or sarcoma. 

With the exception of certain nodular varieties, which 
may perhaps be compared to the syphilitic granulation tu- 
mors (Kuhn-Manasse), these forms are rarely demonstrated 
by laryngoscopic examination, as they possess a marked ten- 
dency to undergo ulceration. 

The ulcers vary in size and depth. Those which develop 
from infiltrations are wide-spread and flat, while those which 
follow gummata are deeper, and correspond in size with the 
gumma which they replace. Their boundaries are sharply 
defined, the edges are undermined, elevated above the sur- 
face, and thickened, while the surrounding area is the 
seat of a dusky red discoloration, more or less distrib- 
uted over the entire larynx. "The floor of the ulcer is 
covered with a thin, grayish, creamy exudate, the removal 
of which reveals the whitish speckled appearance of the 
firm infiltration " — (Orth). The differential diagnosis from 
tubercular ulcers is based on the sharp edges, the speckled 
floor, the absence of nodules in the surrounding area, 
and the absence of any tendency to the formation of granu- 
lations, although there are cases in which the diagno- 
sis can be decided only by a bacteriologic or a general 
examination. It must also be borne in mind that syphilis 
and tuberculosis are not rarely associated, as was pointed 
out in various papers by Schnitzler. Moreover, we learn 
from daily experience that even when the external appear- 
ance of the ulcer fails to afford any diagnostic points, the 
diagnosis may be inferred from its situation in the larynx. 
While tuberculous ulcers are preferably found on the pos- 
terior laryngeal wall, and on the posterior extremities of the 
vocal cords, syphilis affects chiefly the ligamentous portion 
of the vocal cords. While tuberculosis is frequently uni- 
lateral, especially when it appears in the vocal cords, the 
syphilitic ulcers are always bilateral, and very often dis- 
tributed symmetrically on the free borders, being evidently 
produced by contact of opposed portions of the cords. 
Tubercular ulcers usually occupy the surface of the vocal 
cords, while syphilitic ulcers are situated on the free border, 
and give to it a dentated appearance. The ulcers event- 
ually break down and lead to tissue destructions which 
differ greatly in extent. The appearance of the laryngeal 
image varies widely, as any one can convince himself by 



2l8 THE SKIN AND THE SEXUAL ORGANS, 

glancing through Schnitzler's or Krieg's "Atlas." Edema 
is not characteristic of syphilis, as some authors maintain ; 
it always depends on ulceration or on perichondritis. The 
latter may be primary or secondary, more frequently 
secondary, and develops in any case of deep ulceration of 
the cartilage ; it is, of course, followed by necrosis and 
exfoliation of the diseased portions, and the resulting defects 
in the framework of the larynx may give rise to great de- 
formities and malpositions. Syphilitic is much less frequent 
than tubercular disease of the cartilage. 

As syphilis readily yields to specific remedies, unas- 
sisted by local treatment, it often leaves conspicuous alter- 
ations, due to cicatricial contraction or to connective-tissue 
neoplasms, while tuberculosis of the larynx, owing to its 
unfavorable prognosis, rarely comes under observation in 
the stage of regeneration. The scars, which vary in depth 
and size according to the ulcers that they replace, are stel- 
late in form, and by their contractions often produce dis- 
tortions in isolated portions of the larynx, so that not only 
the vocal cords and ventricular bands, but also the aryepi- 
glottic folds and the epiglottis, may be so displaced by the 
contraction of the scar that the relations in the laryngeal 
image are much disturbed. Subjective symptoms are 
usually wanting. On the other hand, adhesions between 
neighboring parts are common, especially between the 
vocal cords, which are usually both ulcerated along their 
free borders, and therefore present a favorable seat for the 
formation of synechiae. The cords in such cases are 
united by cicatricial membranes, which always begin at 
the anterior extremity and extend for a variable distance 
backward, interfering with the mobility and function of the 
cords, very frequently giving rise to severe dyspnea. The 
ulceration in the epiglottis is sometimes so great as to 
destroy one-half of the structure or one entire free margin, 
and if, as frequently happens, it is bent backward and an 
adhesion forms between it and the aryepiglottic fold, the 
lumen of the larynx becomes obstructed and serious em- 
barrassment of respiration may result. 

Hausemann i recently described a certain cicatricial 
lesion on the epiglottis that he often had occasion to 
observe at autopsy, having found it in 25 out of 42 cases 

1 " Berlin, klin. Wochen.," 1896, No. II. 



SYPHILIS. 219 

of syphilitic subjects. The epiglottis, from the frenulum to 
the upper border, was the seat of a process resembling the 
so-called smooth atrophy of the base of the tongue, first 
seen by Virchow and minutely described by Lewin.^ 
We omitted this because it is of no value in clinical diag- 
nosis. The effect of the lesion was to draw the cartilage 
forward so as to effect an anteflexion of the epiglottis. 

Among permanent postsyphilitic alterations we must 
mention a diffuse hyperplasia of the mucous membrane, 
which may lead to extensive stenosis of the larynx and 
dyspnea, if it occurs below the vocal cords. We find it 
mentioned by Neumann^ ; and Eppinger^ describes it as 
a fibroid degeneration accompanied by ulceration or cica- 
trization and producing a diffuse puckering of the mucous 
membrane, such as Tiirck described after his so-called 
"parenchymatous inflammation of the mucous mem- 
brane." Whether the hyperplastic condition of the squa- 
mous epithelium — which has been called, after Virchow, 
pachyderma laryngis — is due to syphilis is not definitely 
known, but it seems probable. 

I once saw paralysis of the vocal cords (paralysis of the 
right posticus) in secondary syphilis, which yielded to anti- 
syphilitic treatment. A few other cases are found in the 
literature. The most natural explanation for this occur- 
rence is enlargement of the mediastinal or peritracheal 
lymph-glands exerting pressure on the nerves, as syphilitic 
neuritis of the nerve-trunk is unknown. 

Syphilis of the ear is definitely known to occur only in 
those parts which can be directly inspected : that is, on the 
external ear, in the external auditory meatus, on the drum- 
head, in the region overlying the mastoid process, and, with 
the aid of posterior rhinoscopy, on the pharyngeal orifices 
of the tubes. The external ear presents all the alterations 
that are seen as the expression of secondary or tertiary 
syphilis on the external skin, and in the much-quoted case 
of Zucker* even a primary affection of the external ear was 
demonstrated. The manifestations on the skin of the ex- 
ternal ear correspond in time of appearance and morphology 
with syphilis of the external skin. Thus, we find roseola, 
papules, and condylomata in the secondary nodular syphil- 

1 " Virch. Arch.," vol. CXXXVIII. ^ ^^^_ ^^y^ p ^q. 

3 " Handb. der pathol. Anatomie," Klebs, 7th ed., p. 123. 
•* "Zeitschr. f. Ohr. ," IX. 



220 THE SKIN AND THE SEXUAL ORGANS. 

ids, and gummata in the tertiary stage. The cases re- 
corded in the Hterature are comparatively few, and confirm 
what we learn from statistical sources of the infrequency of 
these complications. The course of the papular form in 
the external meatus is remarkable ; it was first carefully 
described b}^ Stohr^. The wall of the meatus at first shows 
a muddy, bluish-red discoloration ; this is followed by 
swelling and diffuse redness embracing the tympanic mem- 
brane, in which Stohr also observed similar muddy, bluish- 
red patches. A few authors (Kretschmann, Lang) observed 
papules on the tympanic membrane, described by Lang as 
pale, glistening patches, the size of a millet seed, over the 
processus brevis. In the auditory meatus the papules lead 
to excoriations ; the walls become very much swollen, and 
there is a copious flow of bloody, purulent fluid. Later, 
these excoriated patches become the seat of excrescences 
which eventually lead to the formation of condylomata pre- 
senting themselves as villi or polypoid structures with 
small bases, either within the external meatus or protrud- 
ing from the canal. According to Christinneck, there is a 
tendency to the formation of circular ulcers at the entrance 
of the external auditory meatus. 

The diagnosis of these affections is based on the pres- 
ence of constitutional syphilis, as they are very easily con- 
founded with otitis externa eczematosa or with granulations 
due to some other cause. 

Gummata have been described on the external ear 
(Hessler '^), on the bony wall of the external auditory 
meatus (Brieger,^ Habermann ^) ; on the tympanic mem- 
brane (Baratoux ^) ; in the mastoid process, both central 
(Schede,^ Haug ^) and in the periosteum (Pollak,^ 
Brieger ^) ; they present no special characteristics. These 
affections all yield to antisyphilitic treatment, but they 
leave scars which may produce marked stenosis of the 
external auditory meatus, or periosteal deposits and exos- 
toses on the bony portions of the external meatus and on 
the mastoid process. 

The pharyngeal orifices of the Eustachian tubes may 

1 "Arch. f. Ohr.," V, p. 130. 2 « Arch. f. Ohr.," xx, p. 242. 

* " Beitr. z. Ohrenheilk.," p 161. * " Schwartze's Handb.," I, p. 277. 

5 " Rev. mens, de lar.," 1885, No. 7. 

•^ Quoted from Kloos, " Schwartze's Handb.," I, p. 486, | 29, No. 14. 

" " Arch. f. Ohr.," XXXVI, pp. 201, 202. 

« See " Arch. f. Ohr.," xvin, p. 204. 



SYPHILIS. 22 1 

share in the syphihtic process in a variety of ways ; they 
may be the seat of primary syphihs in consequence of in- 
fection by a polluted catheter, or they may be attacked 
during the secondary and tertiary stages in connection 
with the postnasal space and become involved in the re- 
sulting cicatricial contractions and adhesions. The seat 
and the nature of the disease are easily demonstrated by 
a rhinoscopic examination after symptoms in the middle 
ear, retraction, opacities, difficult hearing, and tinnitus 
aurium have aroused the suspicion of tubular occlu- 
sion. Suppuration from the middle ear is common in 
syphilitic subjects. So far, our clinical and anatomic 
observations do not justify us in regarding it as a specific 
suppuration, since it has not been possible to demonstrate 
the occurrence of irritative syphilitic processes in the mid- 
dle ear, although theoretically the existence of syphilitic 
disease of the middle ear seems plausible. " Authorities 
in the main agree that in acute and subacute simple, as 
well as in acute and chronic purulent, affections of the 
middle ear occurring in the course of syphilis, the nasal 
and pharyngeal disease plays an important role" (Be- 
zold 1). The same etiology may be assumed for suppu- 
ration from the middle ear in hereditary syphilis. Fournier,^ 
it is true, says that these suppurations may constitute the 
primary manifestations of hereditary syphilis, and mentions 
the absence of pain as a characteristic symptom in such 
cases, but his observations are not satisfactory from an 
otologic standpoint, and do not carry much weight. 

Exudative inflammation of the middle ear is mentioned 
by Schwartze ^ ; and Kirchner ^ subsequently observed 
such a case, which was, however, complicated by the ex- 
istence of ulcers in the nasopharynx. At the autopsy 
Kirchner found in the middle ear, besides a serosanguin- 
eous exudate, round-celled infiltrations, split-pea-shaped 
neoplasms in the bone, and a constriction of the blood- 
vessels, which he interpreted as a syphilitic endarteritis. 
Kirchner's case is, however, not very convincing, and it 
seems remarkable that in his microscopic investigations he 
did not take any account of the fact that the cadaver had 

1 "Arch. f. Ohr.," xxi, p. 260. 

2 Lectures on Late Hereditary Syphilis, translated by Korbl and Zeissel, 
1894, p. 150. 

3 " Arch. f. Ohr," VI, 267. *" Arch. f. Ohr. ," xxviii, p. 172. 



222 THE SKIN AND THE SEXUAL ORGANS. 

been in water several days, and that he found no post- 
mortem changes. Finally, a form of sclerotic middle-ear 
catarrh has been described as a consequence of syphilis. 
Gradinego ^ and Chambellan ^ assume a sclerosis of the 
middle ear, which the former explains as a parasyphilitic 
affection in hereditary lues. 

There is a form of syphilis affecting the nervous appara- 
tus of the organ of hearing the existence of which is based 
solely on clinical observation. During the tertiary, and 
even more frequently during the secondary, stage, a few 
weeks after the appearance of the skin eruption, the patient 
suddenly complains of severe headache and loss of hearing, 
which may go on to complete deafness within a few days ; 
the condition is always accompanied by tinnitus aurium or 
other subjective noises or harmonic tones, sometimes with 
vertigo and vomiting, and Schwartze ^ adds to these symp- 
toms a reeling gait in the dark. The disease is usually 
unilateral, occasionally bilateral. Otoscopic examination 
reveals no alterations, but the functional test shows that the 
lesion is in the nervous path : Rinne's test is positive, and 
when the tuning-fork is placed on the head the tone may 
suddenly change to the healthy side ; frequently there is 
inability to hear high-pitched notes. Gradenigo ^ de- 
scribes three different varieties, according to the course of 
the inflammation : a slowly progressing, a rapidly progress- 
ing, and one with apoplectiform onset. Fourniervery cor- 
rectly points out a similarity between the latter form and 
the loss of hearing in tabes, without, however, recognizing 
an etiologic connection for all cases. 

In the hereditary form there is a disease of the inner ear 
analogous to that which occurs in tertiary syphilis. It 
occurs principally between the ages of ten and twenty (six 
to eighteen), and is frequently associated with interstitial 
keratitis and Hutchinson's teeth, although it is much rarer 
than the ocular disease ; Fournier met with it in only 40 
out of 212 cases. Gradenigo says that the power of 
hearing often varies from one day to the next, but except 
for this, and the fact that the disease is always painless and 
bilateral, it does not differ from the form seen in acquired 

1 "Arch. f. Ohr.," xxxviii, p. 310. 

2 " Ann. des mal. de I'oreille," 1895, p. 267. 
' " Chirurg. Erkrank. des Ohres," p. 376. 

* " Schwartze's Handb.," II, p. 424. 



SYPHILIS. 223 

syphilis. There is, however, a marked difference in the 
matter of prognosis; for, whereas secondary and tertiary ner- 
vous diseases of the ear may be favorably influenced or even 
cured by antisyphilitic treatment if they are taken in hand 
early, the prognosis in the hereditary form is unfavorable. 

The term "nervous disease of the ear in syphilis " has 
been used designedly, as the seat of the lesion is unknown. 
The value of the investigations in regard to histologic 
changes in the labyrinths of syphilitic subjects is impaired 
by the fact that the etiology in these cases of alleged heredi- 
tary syphilis is doubtful (see Gradenigo ^) ; and, in the 
second place, the changes found in secondary and tertiary 
syphilis — described as round-celled infiltration, calcifica- 
tions, and hyperemia — are so general that nothing is gained 
for the pathology by the recording of such doubtful cases, 
which can only by much ingenuity be brought into har- 
mony with the classic description of syphilis. There is a 
general tendency to ascribe syphilitic deafness to disease of 
the vestibule and of the first turn of the cochlea, but there 
is nothing to justify such an assumption, and the seat of the 
disease might just as well be placed in the nerve-endings or 
in the nerve -trunk itself. 

In an interesting variety of cases the loss of hearing is 
due to direct lesion of the auditory nerve or of its centers 
by a gumma in the brain, or gummatous basal meningitis, 
or cerebrospinal meningitis ; for the auditory nerve may 
be implicated in this disease as well as any of the other 
cranial nerves. Such a case is described by Oppenheim,^ 
who in another place (p. 16) remarks that "it may event- 
ually be possible to demonstrate the same symptoms in the 
auditory nerve — which, up to the present time, has been 
rather neglected (treated like a stepchild) — that have been 
accurately observed in the ocular, motor, and facial nerves." 
Schwartze^ mentions a case of intracranial syphilitic paral- 
ysis of the left auditory nerve, associated with paresis of 
the left arm and paralysis of the tongue, but without facial 
paralysis ; Gradenigo'* quotes a case from Helmet of sud- 
denly developing deafness in a young syphilitic woman, in 
which, at the autopsy, scattered foci of encephalitis were 
found, one of them at the exit of the auditory nerve-trunk. 

^ " Schwartze's Handb.," il, p. 431. 

^ " Syphil. Erkrank. des centr. Nervensystems," 1890, p. 30. 

3 "Arch. f. Ohr.," IV, p. 267 (1869). * " Schwartze's Handb.," II, p. 529. 



X. DISEASES OF THE EYE. 



J, RELATIONS BETWEEN THE EYE AND 
THE NOSE. 

During the past few years particular attention has been 
directed to the relations existing between the eye and the 
nose, and it is being recognized more and more that patho- 
logic conditions of the nose play an important part in the 
genesis of ocular diseases. Although the cases that tend 
to throw light on this etiologic connection are not numer- 
ous, they are all the more convincing. Seifert, ^ in a series 
of investigations in v. Michel's eye clinic, found nasal dis- 
ease in all but 2 among 38 cases of dacryocystoblennorrhea. 
In another series of 48 cases the nose was regularly in- 
volved. Winckler,^ among all the children which he 
examined in the course of three years in the Children's 
Hospital at Bremen, found the nose diseased in 50^ of 
those suffering with scrofulous eye disease, and Ziem^ gives 
it as his belief that two-thirds of all cases of ocular disease 
are due to disease of the nose. 

It is often difficult to determine after a single examina- 
tion whether or not there is any connection between the 
nose and the eye, as the conditions in the nose are much 
influenced by the presence of swelling, and the amount of 
mucus is variable, especially in scrofulous patients, who 
furnish the bulk of the material. Hence, the question 
whether or not the nose is diseased depends more or less 
on the judgment of the examiner and on his standard of 
regularity in structure and degree of moisture for the nor- 
mal nose. Ziem appears to have the highest standard in 
this respect, and this may explain his large percentage of 
nasal disease accompanying disease of the eye, and, as will 

1 " Miinch. med. Wochen.," 1898, No. 29. 

2 '< Semon's Centralbl.," xii, p. 92, and '• Bresgen's Sammlung," Bd. 
in., H. I. 

3 "Mon. f. Ohr.," 1893, Nos. 8 and 9. 

224 



RELATIONS BETWEEN THE EYE AND THE NOSE. 2 25 

be mentioned later, his radical views in regard to interde- 
pendence between eye and nose. Thus, before admitting 
the integrity of the nose he subjects it to a test irrigation, 
as, he says, "this procedure often reveals the presence of 
pus which escaped the detection of anterior and posterior 
rhinoscopy." For my part, the finding of mucus or pus 
in the irrigating fluid after a nasal douche would not con- 
vince me of the existence of nasal disease unless I was 
able at the same time by inspection to determine the origin 
of the pus ; if the nose is really diseased to such an extent 
as to be capable of affecting the eye, the diagnosis can 
always be made with the aid of rhinoscopy, without using 
a nasal douche. It is this divergence of opinion in regard 
to what constitutes the difference between a healthy and a 
diseased nose that is responsible for the different views held 
as to the frequency of a relationship between the nose and 
the eye, and for the fact that many physicians (Ziem and 
others) consider it a proof of etiologic connection between 
a nasal and an ocular disease if the ocular disease is favor- 
ably influenced by local treatment of the nose. Thus, we 
meet with cases of disease of the uveal tract and of visual 
disturbances that are ascribed to a pathologic condition of 
the nose, because galvanocautery or some other local inter- 
ference is followed by improvement in the ocular symptoms, 
although no good internal evidence can be adduced to 
prove the connection between the two diseases. 

There are three possible ways in which disease may be 
transmitted from the nose to the eye : through the lacrimo- 
nasal duct, through the blood and lymph streams, and 
by way of the nerves. 

The most important role in the production of consecutive 
eye disease belongs to the lacrimonasal duct, on account 
of its anatomic relations to the nose. The location of its 
mouth in the inferior nasal meatus, below the inferior 
turbinate bone, close behind its anterior expanded extremity,, 
readily explains the occurrence of disease of the tear-ducts 
whenever the normal drainage of the lacrimal fluid becomes 
obstructed, or when disease of the nose spreads to the 
lacrimonasal duct and to the lacrimal sac. In addition,, 
the latter may be the means of causing disease of the con- 
junctiva and of the cornea by direct transmigration of 
pathogenic organisms from the nose to the eye. 

Epiphora and blennorrhea of the lacrimal sac regularly 
15 



226 THE EVE. 

follow obstruction of the nasolacrimal canal. The obstruc- 
tion may be due to various conditions in the nose, such as 
acute and chronic hypertrophies, tumors, ulcerations, and 
cicatricial contractions whenever they are seated in the 
inferior nasal meatus. Of course, the influence of a tem- 
porary disease, such as acute rhinitis, is not very great, and 
it is only after chronic conditions that we have lasting 
affections of the lacrimal sac. Among these must be 
mentioned particularly the hypertrophic conditions found 
in scrofulous children, and the polypoid hypertrophies of 
the lower turbinate body reaching down to the nasal floor 
and completely obstructing the inferior nasal meatus. Even 
milder grades of hypertrophy may exert a very injurious 
influence if the septum is deformed and its covering puck- 
ered in folds. Here belong also hypertrophic conditions 
of the nose due to obstruction of the nasopharynx, and 
we therefore find in adenoid vegetations of the pharnygeal 
vault one of the most fruitful sources of ocular disease. 
Even an atrophic rhinitis may under certain conditions lead 
to disease of the lacrimal sac, although the opening of the 
lacrimonasal duct necessarily shares in the general dilatation, 
for the walls of the nose, including the orifice of the 
lacrimonasal duct, may be entirely covered over by the 
closely adhering crusts of dried secretion. In this connec- 
tion special mention must be made of those forms of ozena 
in which the lower turbinate bodies have been destroyed in 
consequence of caries of the bone due to the rhinitis foetida 
atrophica, or genuine ozena, or to syphilitic ozena. In 
such cases the orifice of the lacrimonasal duct, which may 
be abnormally expanded as a result of atrophy of the 
mucous membrane or of cicatricial changes, opens directly 
into the nasal cavity, so that the crusts which cover the 
nasal walls may completely occlude it, an event which can 
not take place as long as the inferior turbinate bone is 
present and affords a certain protection. Thus, we see some 
of the most obstinate cases of blennorrhea of the lacrimal sac 
in hereditary syphilitic ozena, in which, particularly in 
the case of young children, the turbinate bones and the 
septum are destroyed and the entire nasal cavity is com- 
pletely filled with hard, stinking crusts, which can be removed 
only with great difficulty by means of the douche and a 
cotton-carrier. Their rapid recurrence can, at best, only 
be delayed by the most conscientious regularity in treat- 



RELATIONS BETWEEN THE EYE AND THE NOSE. 22/ 

ment, so that we can readily understand the frequent re- 
lapses and the chronic course of the ocular complication. 
Tumors rarely lead to obstruction of the inferior nasal 
meatus in their early stages, as they usually spring from the 
region of the ethmoid bone. The same is true of nasal 
polypi, as they rarely occur in the anterior half of the lower 
turlDinate body, and can not, therefore, affect the tear-ducts 
by direct obstruction of the orifice ; they do not become 
important until they have grown so large and so numerous 
as to fill every part of the nasal cavity. 

Lastly, we have ulcerative processes and granulations, 
such as occur in tuberculosis, lupus, syphilis, rhinoscleroma, 
leprosy, glanders, etc. These may lead to stenosis or occlu- 
sion of the canal, even after they have healed, by reason 
of the cicatricial contractions and adhesions which remain. 

The effects of the nasal disease are not always limited to 
occlusion of the lacrimonasal duct ; the infection may spread 
through the canal of the eye itself and lead to inflammations of 
the lacrimal sac, to conj unctivitis, and to keratitis. It is in this 
way that we explain the occurrence of eczematous keratitis 
and conjunctivitis in connection with eczema of the vestibule 
and chronic hypertrophic rhinitis in scrofulous individuals, 
as demonstrated by Knies in 90 /^ of cases occurring in 
children. 1 It is interesting to note that Seifert^ found 
rhinitis foetida atrophica in the great majority of all cases 
of spreading ulcer of the cornea, so that he was led to infer 
the extension of an infection of the cornea from the nose. 
Buck 3 mentions corneal ulcers following ozena. According 
to Fuchs,^ ozena is a frequent complication of trachoma; 
and Klunzinger, Ziem, Gerber, and Kuhnt assume a con- 
nection between trachoma and disease of the nose, on the 
ground that the "granulosis of the nose" may set up a 
secondary granulation in the lacrimal apparatus and on the 
palpebral conjunctiva — a view which is not confirmed by 
other authors. Although Lowenberg's ozena bacillus has 
been found in the conjunctival sac by Terson and Gabriel- 
ides, ^ and although Abel '^ also found his bacillus mucosus 

1 Knies, "Die Beziehungen des .Sehorgans und seiner Erkrankung," 
p. 285. 

"- "Miinch. med. Wochen.," 1898, No. 29. 

3 Ref. "Semon's Centralbl.," XI, p. 217. 

4" Lehrb. der Augenheilk.," p. 570. 

5 " Arch, d'ophthalm.," XIV, p. 488, quoted from Schmidt- Rimpler. 
" Nolhnagel's Ifandb.," XXI, p. 430. 

«"Zeitschr. f. Hygiene," Bd. xxi, II. I. 



228 THE EYE. 

ozceii(2, no local lesion directly due to the micro-organisms 
could be demonstrated in the eye in either case. 

Despite the fact that it is generally assumed that diseases 
are transmitted through the lacrimal duct only from the 
nose to the eye, and that transmission in the other direc- 
tion is not considered important, this method does, never- 
theless, appear to play some part in gonorrheal infection 
of the eyes, as Miller ^ repeatedly found the nasal mucous 
membrane diseased in blennorrhea neonatorum, and was 
able to demonstrate the presence of gonococci. 

Transmission of tuberculosis of the nose to the lacrimal 
sac has been observed (Wagonmann-Fuchs ^), and lupus 
also may spread to the eye. 

Batut 3 reports two cases of diphtheric disease of the 
nose and eye without bacteriologic findings. 

It is well known that there is an intimate relationship 
existing between the vascular system of the nose and that 
of the eye. Arterial anastomosis between the nose and the 
eye is effected by means of the ethmoid arteries, by 
branches of the ophthalmic, and b}^ a collateral trunk along 
the lacrimonasal duct, which joins the angular, the ophthal- 
mic, and a branch of the infra-orbital arteiy — (Zuckerkandl). 
In the same way a communication is established by means 
of a network of veins between the lacrimal plexus and the 
veins of the nose, the orbit, and the face ; besides, there are 
larger venous trunks running from the nose to the cranial 
and orbital cavities — the ethmoid veins. Ziem lays the 
greatest stress on the connections between both the arterial 
and the venous systems in the etiology of ocular disease 
accompanying disturbances of the nasal circulation, which 
occur in acute and chronic inflammations and in the passive 
hyperemias that are so common in the nose. But as these 
disturbances are followed by disease of the eye only in com- 
paratively rare instances, Winckler believes that the cause 
is to be sought in individual anomalies in the anastomoses.'* 
Conjunctivitis as well as blepharitis and epiphora are fre- 
quently observed to follow circulatory disturbances of this 
kind occuring in acute and chronic hypertrophic conditions, 
and in almost every variety of nasal stenosis, but the doc- 

1 Stork, <' Nothnagel's Handb.," xni, i. Th., i. Abth., p. 86 (note). 

2 " Lehrb. der Augenheilk.," p. 570. 

^ " Ann. des mal. de I'oreille," 1S93, p. II4. 

* E. Winckler, " Bresgen's Sammlung, " ni, H. i. 



RELATIONS BETWEEN THE EYE AND THE NOSE. 229 

trine of Ziem ^ that diseases of the uveal tract often origi- 
nate in this way has not found many adherents. 

The following cases are probably to be ascribed to circu- 
latory disturbances : Straub ^ reports a case in which there 
were attacks of pain and congestion in both eyes, lasting 
from two to six days, accompanied by epiphora and proto- 
phobia ; he assumes a vasomotor neurosis originating in 
the nose, as removal of a crista septi and cauterization of 
the hypertrophic turbinate bodies was "followed by almost 
complete cure." Dunn ^ saw a case of recurring edema of 
the upper eyelid which disappeared after removal of the 
anterior extremities of both middle turbinate bones, which 
were the seat of polypi. 

The fifth nerve supplies a part of the nose through a 
branch of its first division ; the innervation of the septum, 
the vestibule, and the external skin of the nose being 
effected by the external and internal branches of the nasal 
nerve. 

This nervous connection explains the reflex sensations in 
the nose — tickling and sneezing — which follow irritation of 
the ciliary nerve when the eye is suddenly subjected to a 
strong light, as, for instance, when we look into the sun, or 
in inflammatory disease of the. eye. On the other hand, 
irritation of the ocular nerves by way of the branches of the 
fifth which we have just described in disease of the nose is 
much more common. Its simplest expression is seen in 
the redness of the conjunctiva and the lids and in the in- 
creased flow of tears which follow the slightest local inter- 
ference in the nose, even the mere touching of the corre- 
sponding side of the nose with a probe. In this category we 
may include a ciliary neurosis described by Seifert,* due to 
synechiae, after extensive cauterizations in the interior of 
the nose. 

Quite a number of other ocular affections have been 
ascribed to primary nasal disease, without, however, suffi- 
cient proof of the etiology and the manner of the reflex 
influence being forthcoming. Thus, for instance, Laurens ^ 
divides reflex disturbances of the eye into those which 



^ Compare " Mon. f. Ohr.," 1893, p. 262. 

2 "Nederl. Tijdschr. v. Geneesk.," 1S96; see " Semon's Centralbl.," XII, 
p. 425. 

3 See " Semon's Centralbl.," ix, p. 371. •* Loc. at. 

5 "Ann. d'ocul.," April, 1896; see "Semon's Centralbl.," xii, p. 426. 



230 THE EYE. 

"affect the general or special sensibility of the eye (neu- 
ralgias, photophobia, amblyopia) ; reflex disturbances of 
the motility (blepharospasm, mydriasis, strabismus, asthe- 
nopia) ; and, finally, nutritive and vasomotor disturbances 
in the coverings of the e}^e (conjunctivitis, iritis, glaucoma, 
exophthalmos)." The danger of exaggeration in artifi- 
cially constructing such relations can not well be empha- 
sized too strongly. The reflex connection between the eye 
and the nose, through the agency of the trigeminus, is 
much less extensive than might be supposed from the 
statements of many authors (Fortunati, for instance), who 
would ascribe to the second division of the trigeminus the 
power of producing reflex disturbances in the eye through 
its nasal ramifications, although Ziem goes to the opposite 
extreme and attributes the origin of secondary diseases of 
the eye principally to the agency of the vascular system. 
In proof of the reflex influence of nasal diseases cases are 
reported by Knies,i Schmidt- Rimpler,^ Lieven,^ and E. 
Winckler,* but I shall not repeat them here, as they neither 
prove nor explain anything.^ I may, however, mention a 
few rather spurious examples taken from the latest litera- 
ture, Laurens ^ observed a case of blepharospasm which 
disappeared after obstruction of the nose due to hyper- 
trophy of the mucous membrane and synechias had been 
corrected. He also reports seeing a six-year-old girl with 
left converging strabismus, which disappeared after an 
operation for adenoid growths. On the other hand, 
Baumgarten "^ considers strabismus, which he observed 
twice in hypertrophy of the pharyngeal tonsils, an acci- 
dental complication, as it was not influenced by operation. 
Schloss and Myles ^ report several cases of asthenopia 
which subsided after removal of hypertrophied turbinate 
bodies, the removal of a spine on the septum, and, in some 
cases, of tumors. Myles believes that hypertrophies of 
the tissues, by pressure on the nerves, provoke ocular 
symptoms, but this supposed connection with the nose was 
not proved to exist in all the cases in which a nasal opera- 

1 Loc. cit. 2 i^Qi-_ i-jf_ 3 £u^_ ^//_ 4 i^Q^^ ^//_ 

^ See reports in " Semon's Centralbl." 

s " Presse med.," iSq6, Jan. 22 ; see " Semon's Centralbl.," xn, p. 425. 

' " Neurosen und Reflexneurosen des Nasenrachenraumes," " Volkmann's 
klin. Vortr.," N. F., No. 44. 

*" Pacific Med. Jour.," 1894, and " N. Y. Med. Record," 1894; see 
" Semon's Centralbl.," xi, pp. 280 and 281. 



RELATIONS BETWEEN THE EYE AND THE NOSE. 23 1 

tion was performed. Bernstein ^ speaks of improvement 
in errors of refraction after removal of nasal hypertrophies. 
According to Knies,^ operative interference on the nasal 
membrane is rarely followed by visual disturbances con- 
sisting in concentric narrowing of the visual field with or 
without disturbance of the central sight and of the color- 
sense. Fortunati ^ assumes a nasal origin for two cases of 
neurokeratitis in which ulceration and perforation of the 
cornea, with prolapse of the iris, occurred after a long- 
continued obstruction of the nose. Winckler ^ reports a 
case of retrobulbar optic neuritis with serous tenonitis 
which was treated for six weeks without benefit, and was 
finally cured within a month after removal of papillomata 
on the turbinate bodies. Pupillary changes — mydriasis 
and myosis — have also been described as due to nasal irri- 
tation, as the snuffing-up of cold water into the nose 
(Ostmann ^ ). 

Inflammatory disease of the accessory cavities is always 
accompanied by hypertrophic and polypoid alterations in 
the interior of the nose, which may in turn lead to the dis- 
turbances we have just described. After Ziem, the pioneer 
in this field, Kuhnt'' deserves the credit of describing in a 
comprehensive work the dependence of ocular complica- 
tions on diseases of the accessory cavities, thereby awaken- 
ing the interest of other investigators in many questions 
hitherto much neglected. The lines he laid down were 
followed among others by Schmidt-Rimpler, who has pro- 
duced the latest work on this subject, while the same ques- 
tions have also been extensively dealt with by Griinwald. '^ 
The latter has collected a large number of cases. 

The anatomic position of the accessory nasal cavities is 
such that a morbid process originating within them is easily 
transmitted to the orbits. The lateral wall of the ethmoid 
cells, consisting principally of the os planum (lamina 
papyracea), and completed at the anterior and posterior 
ethmoid walls by the juxtaposition of the lacrimal bone and 
the orbital processes of the palatal bone, also forms the 

1 " Med. News," July 22, 1893 ; see " Senion's Centralbl.," x, p. 386. 

2 Loc. cit., p. 288. 

3 " Arch, d'otol.," 1896, No. 2 ; see " Semon's Centralbl.," xiii, p. 330. 
* " Semon's Centralbl.," xn, p. 92. ^ a ^rch f. Ophthalm.," 43. 
^ " Ueber die entziindlichen Erkrankungen der StirnhShle und ihre Folge- 

zustande," 1895. 

" " Die Lehre von den Naseneiterungen," 2d ed. ; 1896, p. 122. 



232 THE EYE. 

median wall of the orbits ; immediately above it lies the 
frontal sinus, and beneath its floor the antrum of Highmore, 
so that all these cavities have at least one wall in common 
with the orbit. On the other hand, the sphenoid sinus, the 
last of the series of cavities which make up the accessory- 
pneumatic system of the nose, does not possess a very 
intimate relation with the eye, except that the robust layer 
of bone which forms its roof lies in apposition with the 
interior of the cranium, and in rare cases endocranial per- 
forations may be produced and lead to direct injury of the 
optic nerve, but accompanied, usually, by other anatomic 
complications. Berger^ remarks that even a simple in- 
flammation of the sphenoid sinus may lead to retrobulbar 
optic neuritis when the opticosphenoid wall is unusually 
thin or is traversed by fissures. 

Although from an anatomic point of view a pathologic 
relation may exist between these accessory cavities and the 
eye, clinical experience teaches that only certain diseases 
appear to possess a tendency to spread to the orbital cavity, 
depending on the seat and the nature of the particular dis- 
ease. The commonest way in which sequels occur in the 
eye is when in acute or chronic inflammation of the acces- 
sory cavities a serous or purulent exudate is retained, and 
thus produces bulging of the cavity walls. The likelihood 
of pus being retained in an accessory cavity depends on its 
relative position and on the size of the openings by which 
it normally communicates with the interior of the nose ; 
that is to say, the more imperfect the drainage, the 
greater the danger of retention. Thus, in the antrum of 
Highmore and frontal sinus the nasal openings are so un- 
favorably situated that even a slight alteration in the neigh- 
borhood of the opening is capable of producing reten- 
tion. While in the antrum the median wall, which lies 
toward the nasal cavity, the exterior wall (canine fossa), or 
the palatal bone is more likely to bulge than the roof of 
the cavity, directed toward the orbit, yet in the frontal 
sinus it is the orbital wall, which corresponds to the floor 
of the cavity, that is more liable, on account of its extreme 
tenuity, to break down under the weight of the accumulated 
secretion than is the more robust anterior wall. Bulging 
of the lateral nasal wall due to empyema of the antrum may 

1 " Soc. franQ. ophth.," May, 1894; see " Semon's Centralbl.," XI, p. 
573- 



RELATIONS BETWEEN THE EYE AND THE NOSE. 233 

in rare cases produce compression of the lacrimal duct. 
Such an event is much less frequent, however, than dis- 
placement of the globe outward and downward by bulging 
of the orbital wall of the frontal fossa and the resulting dis- 
turbances in the mobility, function, and drainage of the 
eyeball. The protrusion of the eyeball is usually preceded 
by edema at the upper inner angle of the orbit, at which 
point empyema of the sinus sometimes ruptures into the 
orbit and leads to orbital phlegmon. From the tenuity of 
the OS planum, which separates the ethmoid cells from the 
orbit, we should expect to see empyema of these cells fol- 
lowed by disturbances in the eye. This is not the case, 
however, as there is little tendency to retention of the pus, 
because the outlets of the cells toward the nose are short 
and spacious, and the walls of the cells are so thin on either 
side that perforation into the nose easily takes place. 

These remarks do not by any means exhaust the subject 
of the relations existing between the eye and disease of the 
accessory cavities ; there is a host of inflammatory and 
functional disturbances which are said to accompany and 
to be dependent on inflammatory conditions of these cavi- 
ties. Hyperemic and catarrhal conditions of the conjunc- 
tiva and cornea, and diseases of the uveal tract, by sub- 
siding after the recognition and treatment of suppuration 
in the accessory cavities, appear to indicate a mutual rela- 
tionship, although Kuhnt^ justly observes that the removal 
of inflammatory conditions in the accessory cavities plays 
only a secondary part in the treatment of ocular diseases, 
and merely assists and reinforces the general treatment ; he 
does not believe that the ocular disease can be cured in 
this way without careful local treatment of the eye. 

When we come to functional disturbances, we have 
hyperemia and venous stasis of the papilla, and peripapillary 
opacity of the retina in suppuration of the frontal sinus of 
the same side, which, according to Kuhnt,^ always disap- 
pears after removal of pus, thus indicating a connec- 
tion with the disease of the accessory cavity. When 
restrictions in the field of vision occur, they are usually 
bilateral, although more marked on the affected side. 
They are usually accompanied with weakness of the inter- 
nal muscles (Kuhnt). For the sake of completeness we 

^ I.oc. cit., p. 112. 2 ^^^ i-K^^ p 121. 



2 34 THE EYE. 

may mention that Kuhnt does not absolutely deny 
Ziem's statement that cataract may be produced by sup- 
puration in an accessory cavity. Careful investigation is 
urgently needed before the dependence of all these condi- 
tions on suppurations in the accessory cavities can be 
accepted as proved. But meanwhile the meager clinical 
material that has been contributed by reliable investigators 
is not to be disregarded, even if the explanation offered is 
not always quite satisfactory. Kuhnt's theory that absorp- 
tion of purulent or fetid masses from the diseased cavities 
plays the principal part in the etiology of functional dis- 
turbances of the eye, and not the vascular system, as Ziem 
contends, deserves attention. The effect on the nervous 
system of this absorption varies with the individual, and may 
be responsible for a rapid tiring or even a kind of obtuse- 
ness in the optic tract and in the nerve-endings of the 
retina. 

Noninflammatory diseases in the accessory cavities, such 
as malignant tumors, carcinomata, and sarcomata, may 
spread to the orbits and lead to appearances identical 
with those of orbital tumors. Photiades^ reports a reflex 
mydriasis due to endolaryngeal interference for the removal 
of laryngeal polyps. 



2. RELATIONS BETWEEN THE EYES AND THE 
EARS.- 

The eye may be influenced by the ear in various ways, 
and may furnish valuable diagnostic points to the otologist ; 
while, on the other hand, diseases of the eye do not involve 
the ear, if we except a few scattered observations relating 
to the impairment of the power of hearing or to the pro- 
duction of tinnitus aurium by sudden flashes of light, or 
such cases as Stevens',^ in which division of a slightly in- 
sufficient internal rectus was followed by the disappearance 
of tinnitus aurium, or where, after iridectomy for glaucoma 
and optic iridectomy in leukoma of the cornea an improve- 

1 " Semon's Centralbl.," pp. 277, 278. 

2 For extensive report of cases see Ostmann, " Arch. f. Ophthal," 43, p. 
22; Schmidt-Rimpler, Nothnagel's "Spec. Path. u. Therap. ," vol. xxr, p. 
435; Knies, "Beziehungen des Sehorgans und seiner Erkrankung," etc., 
1893, p. 289. 

2 Stevens, " Arch. f. Ohr.," xix, p. 75. 



RELATIONS BETWEEN THE EYES AND THE EARS. 235 

ment in hearing was noted/ or where, as reported by 
Wolf, 2 subjective aural sensations occurred during attacks 
of glaucoma. 

Reflex irritation of the eye originating in the ear plays an 
important part in these relations, while direct injury of the 
optic nerves depends rather on endocranial sequels of optic 
disease than on disease of the ear itself Reflex irritation 
may give rise to disturbances in the function of the eye 
muscles, as the vestibular and cochlear branches of the 
auditory nerve are in close relation with the optic pathway. 
There is no doubt that the vestibular nerve may exert an 
influence on the coordinating center that presides over the 
action of the ocular muscles, and that irritation of the nerve 
itself or of its endings in the ampulla and in the membra- 
nous semicircular canals may produce motor disturbances 
in the domain of the oculomotor, the abducens, and the 
trochlear nerves, manifesting themselves in nystagmus, 
ocular palsy, and disturbances in the pupillary reaction. 
This has been proved by numerous physiologic experiments 
on disturbances of equilibrium following injury of the laby- 
rinth, and particularly by Stein, ^ who was perhaps some- 
what hasty in applying unfinished theories to practical 
diagnosis. This reflex connection has been utilized in the 
diagnosis of aural vertigo. For the transmission of re- 
flex irritation from the ear to the eye by means of the 
vestibular nerve we possess some anatomic basis, but for 
the connection between the cochlear nerve and the ocular 
nerve the anatomic basis is not equally clear, and rests 
solely on the occurrence of aural hallucinations, as described 
by Bleuler, Lehmann,^ and Urbantschitsch. 

We have, however, in Held's investigations an important 
contribution to the physiology and pathology of the nervous 
system, which may eventually lead to the overthrow of the 
vague theories at present prevailing concerning the reflex 
connection between the ear and the eye, and furnish a posi- 
tive proof that auditory stimuli are capable of affecting the 
movements of the muscles. Held's '^ investigations re- 
sulted in the demonstration of a reflex arc by which audi- 

1 Knies, loc. ciL, p. 291. - " Arch. f. Augen u. Ohr.," IV. 

3 Arb. a. d. Bazanow'scben KHnik i, i, Moscow, 1897; "Zeitschr. f. 
Ohr.," vol. XXVII. 

* " Zwangsmassige Licbtempfindiint^durcli Scball und verwandte Erschein- 
ungen auf dem Gebiete der Sinnesnerven." 

5 " Arch. f. Anat. und Entwickelungsgesch.," 1S93, p. 201. 



236 THE EYE. 

tory stimuli may be transmitted to the motor apparatus of 
the eye, for he proved that auditory stimuH can be commu- 
nicated to the oculomotor, trochlear, and abducens nerves 
by way of the reflex arc common to the optic and auditory 
nerves, having its origin in the anterior corpora quadri- 
gemina. This same reflex arc also includes other paths by 
which auditory stimuli may reach the nucleus of the facial 
nerve and the formatio reticularis, and can probably be 
transmitted from these to the respiratory, vasomotor, and 
other centers. 

The reflex movements which follow auditory stimuli, and 
consist in turning the eyes or the head toward the side 
from which the sound proceeds, may be explained in the 
same way; they suggest the possibility of pathologic pro- 
cesses in the ocular muscles manifesting themselves as 
atactic movements, being produced by improper or irregu- 
lar irritation of the cochlear nerve. 

If auditory stimuli are capable of producing coordinated 
movements of the eyes by means of this reflex arc when the 
hearing is normal, it is conceivable that when in disease of 
the ear the sound is not heard with equal intensity on both 
sides, the sound waves, being perceived in a different way 
on the two sides, may possibly produce a different reflex 
irritation on the two optic tracts. 

If the coordinating center for a properly regulated move- 
ment of the eye receives an impulse of normal strength from 
one cochlear nerve and a weaker impulse, or none at all, 
from the other, the equilibrium in the coordinated muscular 
movement may be disturbed, and atactic movements of the 
optic muscles are produced. In this way we may perhaps 
explain cases like Biirkner's,^ in which the effort of the 
right ear, which was the seat of a suppuration, to catch the 
sound during the functional test was followed by nystagmus. 
The effect is always bilateral, because of the decussation of 
the deep roots of the ocular nerves ; unilateral reflex dis- 
turbance of the eye through the ear is impossible. 

The ocular phenomena that follow increased pressure 
in the middle ear are due to the pressure changes commu- 
nicated to the labyrinthine fluid by the simultaneous pres- 
sure on the fenestrse, and it is probable that the reflex 
irritation follows the same paths of the vestibular and coch- 

1 " Arch f. Ohr.," xvii, p. 1S5. 



RELATIONS BETWEEN THE EYES AND THE EARS. 237 

lear nerves that we have just described. Lucae ^ was able, 
by raising the pressure in the middle ear through the ex- 
ternal meatus in a case of perforated ear-drums, to produce 
vertigo, which was proved to be optic in character by the 
fact that it immediately disappeared when the eyes were 
closed. As in Lucae's cases crossed double images were 
produced, he argues " that the increased pressure led to 
irritation of the abducens nerve." 

I have given this short description of the physiologic 
possibility of reflex ocular movements being produced by 
irritation in the ear so as to throw some light on the clinical 
cases which have been described as belonging to this cate- 
gory. 

Nystagmus has been said to follow irrigation of the 
external meatus, and to occur in cerumen concretions, in 
purulent otitis media, and after extraction of polyps from 
the middle ear. In those cases where the reflex is pro- 
duced by local influences in the external meatus and on the 
drum membrane, in irritation and in accumulations of 
cerumen, reflex irritation must be explained by pressure 
changes in the labyrinthine fluid, as in the case described 
by Lucae. To what extent the trigeminus may be con- 
cerned in reflex connections between the ears and the eyes 
is not definitely known, although reflex irritation of the 
ocular muscles through this nerve seems possible in view 
of the connections which are known to exist anatomically. 
That the trigeminus may be concerned in the reflex irrita- 
tion appears to be indicated by the fact that the temperature 
of the fluid used in irrigation has some effect on the pro- 
duction of reflex ocular movements, as very cold or very 
hot water appears to favor their occurrence. Lucae's 
observation that the reflex irritation which occurred when 
the ear-drum was perforated was absent when that mem- 
brane was intact, can not be utilized to determine whether 
the irritation affects the mucous membrane of the middle 
ear directly or not, as individual peculiarities appear to 
come into play that can not be overlooked. 

It appears to be proved by experience that disturbances 
of coordination may be produced in the movements of the 
eye muscles by pressure changes in the middle ear, such 
as are frequently observed in catheterization. For similar 

1 "Arch. f. Ohr.," xvii, p. 237. 



238 THE EVE. 

disturbances in the course of an acute or chronic purulent 
otitis media, however, the proof is not so clear, as there is 
no anatomic basis for a direct reflex irritation on the ocular 
nerves by inflammatory conditions in the middle ear, unless it 
be by means of the tympanic plexus, and this is exceedingly 
doubtful. The occurrence of nystagmus or other motor 
disturbances in the eye in cases of purulent otitis media 
probably depends on labyrinthine or intracranial complica- 
tions of the ear affection. Ostmann ^ says that "ocular 
symptoms occurring in the course of acute purulent otitis 
media must be regarded as due to tonic spasm within the 
labyrinth or to an intracranial sequela." Jansen 2 considers 
nystagmus a somewhat vague symptom, most probably 
to be referred to an affection of the labyrinth, and, in the 
absence of such an affection and of leptomeningitis, he 
attributes to it a certain significance for the diagnosis of 
sinus phlebitis or periphlebitis in the neighborhood of the 
temporal bone. It may occur in extradural abscesses as 
the result of pressure on the occipital lobe and on the cor- 
tical centers for the ocular movements which it contains. 
He describes nystagmus as bilateral and synchronous, as a 
horizontal or a rotatory and vibratory movement, usually 
short and sharp, sometimes slow and more extensive, 
occurring during fixation of the eyeball. It appears prin- 
cipally when the glance is directed away from the affected 
ear, sometimes as soon as the median line is passed, and 
increases as the eye is moved farther away, whereas when 
the eyeball is rotated toward the affected ear it remains in 
a state of complete rest, or at most indulges in a few inter- 
rupted movements. 

Our knowledge of pupillary anomalies during purulent 
otitis media is very meager. The phenomenon has been 
reported by Schwartze ^ and by Moos. 

While reflex irritation of the trochlear and abducens 
nerves by way of the trochlear nerve is well known to 
occur physiologically after an auditory impression, and 
probably occurs also under pathologic conditions, paralysis 
of these nerves in diseases of the middle ear and of the 
labyrinth must always be referred (as pointed out by 
Habermann 4) to intracranial complications, and in the 

1 " Arch. f. Ophthal.," p. 13. 2.. Arch. f. Ohr.," xxxvi. 

3 " Arch. f. Ohr.," xvi, p. 263. 

4" Verhandl. der D. otol. Gesellsch.," 1898, p. 98. 



RELATIONS BETWEEN THE EYES AND THE EARS. 239 

absence of any conspicuous alterations at the autopsy it is 
to be explained by the existence of a serous meningitis or 
an inflammation of the pia too slight to attract attention. 

Such palsies of the ocular muscles have frequently been 
observed after intracranial complications of an ear affec- 
tion, and in the latest literature ^ on the sequels of diseases 
of the ear we find them described as depending on the 
mode of extension of the disease to the sinuses, the 
serous membranes, and the brain-substance itself 

Another important symptom that accompanies these 
conditions is papillitis of the optic nerve. When it occurs 
in a purulent otitis media, if there is a suspicion of intra- 
cranial complication it is of vital significance, in spite of 
Jansen's 2 statement that "it appears to occur in rare 
cases, even in uncomplicated empyema of the mastoid pro- 
cess or in otitis media, through the agency of the carotid 
plexus," and should always be regarded as a proof that 
the inflammation has spread to the interior of the cranium. 
When chronic purulent otitis media is associated with con- 
gestive papillitis and cranial symptoms, it becomes very 
important to determine whether the two diseases have any- 
thing to do with each other or not. In tuberculous patients 
with chronic middle-ear disease it must always be borne in 
mind that the ocular and cranial symptoms, which may 
appear to simulate otitic meningitis or an extradural or 
cerebral abscess, may have their origin in a tubercular 
meningitis or in cerebral tuberculosis and be in no way 
dependent on the aural affection. 

Sensory disturbances in the eye may be secondary to 
earache transmitted from the tympanic plexus by way of 
the trifacial nerve ; they manifest themselves in the eye as 
pain, increased lacrimation, and injection of the conjunc- 
tival vessels. 

Urbantschitsch's ^ statement that visual acuity may be 
affected by aural disease is not borne out by the results of 
Ostmann's ^ investigations. The mutual influence of audi- 
tory and ocular impressions, which are described by Bleu- 
ler and Hoffman ^ under the names of " Gehorsphotismen " 



1 Jansen, "Arch. f. Ohr.," xxx\'i ; Hessler, " Otogene Pyamie " ; 
Korner, " Die otitischen Erkrankungen," etc. 

2 " Arch. f. Ohr.," XXXVI. ^ i< pflUger's Arch.," XXX, p. 129. 
* "Arch, f Ophthal.," p, 43. 

5 Quoted from Urbantschitscli, " -Schwartze's Ilandb.,"' i, p. 451. 



240 THE EYE, 

and " Lichtphotismen " (aural and ocular hallucinations) 
are as yet of no clinical value. 

The occurrence of blepharospasm with spasm of the sta- 
pedius muscle is to be explained as a reflex irritation due 
to the fact that both the stapedius muscle ^ and the orbic- 
ularis palpebrarum derive their innervation from the facial 
nerve. 

1 Gottstein, " Arch, f, Ohr.," xvi, p. 6i. 



I 



XI. INTOXICATIONS. 

The upper air-passages are very much exposed to local 
injury during intoxications, both when the poison is con- 
tained in the air and thus comes into immediate contact 
with the mucous membrane of the nose, the pharnyx, and 
larynx, and when it is ingested in the form of a fluid or 
solid, and during its passage through the pharynx inflicts 
direct injury on that structure and on the upper margin 
of the larynx. From this point the poison may make its 
way into the interior of the larynx and set up an extensive 
morbid process. The ear escapes, as a rule, unless the 
tubes are involved in hypertrophic conditions of the post- 
nasal space ; hence, the number of substances capable of 
exerting any influence on the ear when taken by the mouth 
is very limited. 

The most frequent symptoms produced by the great 
majority of organic and inorganic chemic bodies by direct 
irritation of the mucous membrane of the upper air-pas- 
sages are hyperemia and sensory irritative phenomena, 
such as sneezing and coughing. 

Their recognition presents no difficulty, as the cause of 
the intoxication can usually be ascertained, and the clinical 
picture presents no special characteristics for the individual 
kinds of intoxications, so that it is not worth while to 
enumerate all the various acids, alkalies, ethereal oils, etc., 
in this place. 

Another group of symptoms which it is customary to 
refer to the action of various poisons can not be accepted 
as toxic phenomena without a reservation. Among these 
we have aphonia, hoarseness, and tinnitus aurium. The 
former is due to " adynamia, when the constitutional effect 
of the poison has so debilitated the entire organism that the 
phonetic function shares in the impairment of all the other 
functions, especially those of the central nervous system" 
(Stuffer 1 on "Toxic Aphonia"). In the literature of al- 
kaloid poisoning we find in particular nervous disturbances 

^ " Arch. f. Laryng.," vol. VI. 
i6 241 



242 INTOXICATIONS. 

of speech mentioned along with these adynamic phenom- 
ena, so that mistakes are very apt to be made in interpreting 
the findings. 

The same apphes to the auditory disturbances, which are 
usually given as tinnitus aurium. When we consider the 
manifold causes that may give rise to this phenomenon ; 
how frequently it is due to circulatory disturbances, which 
play so important a role among the toxic effects of many 
poisons-; and that tinnitus aurium, and even hallucinations, 
often occur after the exhibition of stimulant remedies, we 
realize how easy it is to refer symptoms which really orig- 
inate outside of the ear to a direct toxic effect of the poison 
on the ear itself 

We shall, therefore, mention only those substances which 
produce marked clinical disturbances clearly due to the 
constitutional effect of the poison, leaving out all the symp- 
toms of a vague and indefinite character. 

Acids and alkalies exert a direct caustic effect on the 
mucous membranes that manifests itself in various ways. 
The effect of acids is chiefly that of a cauterizing agent, 
causing constriction of the tissues and the formation of 
crusts, — that is to say, the effect is more superficial and is 
localized in the region where it is applied, — whereas alka- 
lies tend to dissolve the tissues and to produce deep 
destruction involving the entire surface of the mucous 
membrane and not confined to the area of contact. In 
both cases the affected part becomes surrounded by an 
area of marked inflammation and swelling. As the inges- 
tion of liquid poisons is always accompanied with the cau- 
terization of the pharynx and of the entrance to the larynx, 
— that is, of the epiglottis and the aryepiglottic folds, — the 
edema which follows may be very extensive, and the 
patient's life is endangered more by stenosis of the larynx 
than by the toxic effect of the substance itself 

The manner of healing and cicatrization similarly varies 
in accordance with this difference in the effects of acids and 
alkalies ; in the former the resulting scars are smooth and 
superficial, while in the latter we have deep cicatricial con- 
tractions, and particularly the formation of cicatricial adhe- 
sions uniting the upper margin of the larynx with the deeper 
portions of the pharyngeal wall. 

The commonest examples of these two kinds of intoxi- 
cation are poisoning with sulphuric, hydrochloric, and nitric 



ACIDS AND ALKALIES. IODIDES. 243 

acids on the one hand, and poisoning with potassium or 
sodium hydrate and ammonia on the other hand. That 
chlorid of zinc is capable of producing the same kind of de- 
struction of the mucous membranes as an acid is shown by 
a case of v. Jaksch's 1, in which, after the drinking of a 
solution of chlorid of zinc and hydrochloric acid, such as is 
used in soldering (68 gm. of zinc chlorid and 3.5 gm. of 
hydrochloric acid to lOO c.c), laryngeal stenosis occurred 
which necessitated tracheotomy. Among the intoxications 
by inorganic acids we must mention particularly chromic 
acid poisoning, as this substance is a favorite cauterizing 
agent in rhinologic practice. Acute chromic acid poisoning 
may follow the use of only a few centigrams, as in cauter- 
ization of the pharynx, and leads to a general intoxication 
in addition to the local symptoms ; while, on the other 
hand, the chronic form of poisoning, which occasionally 
occurs in employees in chromic acid factories, produces 
deep-seated alterations of the mucous membranes. The 
inhalation of chromic acid in the form of dust at first leads 
to an inflammation of the nasal mucous membrane, which 
is soon followed by arrosions on the septum and on the 
anterior extremities of the turbinate bones, constantly 
accompanied by epistaxis. Ulceration also takes place in 
regions to which the particles of dust may be carried by the 
inspiratory air : that is, the tonsils, the uvula, and the pos- 
terior pharyngeal wall. According to Seifert,^ purulent 
inflammation of the tympanic cavity may also occur by 
extension through the Eustachian tubes. 

The internal administration of the iodids, especially potas- 
sium iodid, is sometimes followed by alarming symptoms 
in the upper air-passages. It is well known that the exhi- 
bition of iodin is always accompanied by a slight swelling, 
redness, and desquamation of the mucous membranes, 
manifesting themselves in more or less marked coryza, lac- 
rimation, pharyngitis, and laryngitis. But, in addition, 
the literature contains a number of intoxications following 
the use of potassium iodid which led to alarming symptoms, 
and in a few cases even necessitated tracheotomy. The 
symptom referred to is edema of the larynx. It has been 
observed in every part of the larynx — on the lateral wall, 
about the entrance, on one side of the larynx only, or on 

1 Nothnagel's "Spec. Path. u. Therap.," vol. I. 

2 " Die Gewerbekrankheiten der Nase," etc., Fischer, Jena, 1895. 



244 INTOXICATIONS. 

both sides in the subglottic region. Our knowledge of its 
cause and of its mode of origin is very meager. The in- 
toxication does not appear necessarily to follow large doses 
of the drug, as cases have been reported in which a short 
course of treatment with small doses produced an intoxica- 
tion (Rosenberg). In two cases reported by Schmiegelow ^ 
in which tracheotomy had to be performed, edema 
occurred after the administration of three teaspoonfuls of a 
5^ solution taken morning and evening in one case, and 
in the other case after only three tablespoonfuls of the same 
solution had been taken three times a day for several 
days. The cases in which the intoxication occurred after 
withdrawal of the drug (Heymann), or after it had been 
used for several weeks, must be considered exceptional, for 
we know that, as a rule, the mucous membrane becomes 
accustomed to the drug after a few days of catarrh ; and, 
even in those cases in which edema of the larynx had 
occurred after a few days' use, the drug was subsequently 
very well borne when it was given in more conservative 
doses. The manner in which the intoxication occurs is as 
little known as its cause ; it is remarkable how seldom grave 
toxic appearances are seen when we consider the enormous 
number of cases which are constantly treated with potassium 
iodid. Rosenberg believes that the occurrence of intoxica- 
tion depends on the presence of glands ; Avellis, arguing 
from an interesting case of unilateral paralysis of the recur- 
rent nerve in which the administration of potassium iodid 
was followed by edema of the larynx on the unaffected half 
of the larynx only, suggests that iodid poisoning takes 
place by way of the nerves, like the angioneuritic edema of 
Striibing ; while G. Lewin, in the face of antagonistic 
observations reported by Rosenberg and others, assumes 
that iodid edema depends on syphilitic disease, on the 
ground that a syphilitic ulcer reacts more intensely to 
iodin. 

The aural symptoms observ^ed after the use of potassium 
iodid consist in tinnitus aurium associated with difficult and 
double hearing. The first two phenomena occur in asso- 
ciation with catarrh of the pharyngeal mucous membrane, 
which has led to acute catarrh of the tubes and its conse- 
quences ; but it seems to me we may also assume that the 

"Arch. f. Laryng.," vol. I. 



ARSENIC AND LEAD. 245 

iodin may exert a direct influence on the mucous membrane 
of the middle ear in the form of swelling and exudation. 
With regard to the remarkable phenomenon of double 
hearing, Moos reports a case in which, after the potassium 
iodid had been taken for six weeks, there followed, in addi- 
tion to the iodin eruption and coryza, a peculiar affection 
of the left ear, so that the notes from d to g were heard 
double, each perception being separated by a short interval. 
I myself once observed, after the use of potassium iodid 
{S%), a case of double hearing for all the sounds of ordi- 
nary conversation which only subsided several weeks after 
the withdrawal of the drug. In the treatment of iodin 
intoxication the preparations of belladonna and sodium 
carbonate have been recommended. 

Arsenic is used in many of the arts, and leads to diseases 
in the nose, in the postnasal space, ^ and in the larynx, 
while the ear is not affected, if we except ulcers in the 
external auditory meatus. When arsenic is taken inter- 
nally, especially in the case of arsenic eaters, aphonia and, 
according to SeHgmiiller,^ paralysis of the vocal cords are 
observed. Unfortunately, these statements lack the sup- 
port of actual observation. The only well-reported case of 
paralysis of the left recurrent nerve said to be due to arsenic 
is contributed by P. Heymann,^ but unfortunately it admits 
of more than one interpretation, as the patient was exposed 
to the fumes of cyanid gas as well as to arsenic, and the 
paralysis may therefore have been due to the effect of that 
substance. 

The catarrh of the nose and of the post-nasal space, 
which, according to Seifert, has been observed by many 
authors, is to be referred to the inhalation of dust particles 
containing arsenic, especially the color known as " Schwein- 
furt green." The excoriations and ulcers which result 
affect particularly the septum, and often lead to perforation 
of the cartilaginous portion. Toeplitz found perforations 
of this kind in 19 out of 31 employees in a chemic factory 
where Schweinfurt green was made ; in other words, in 
6i.3fo. 

Paralysis of the laryngeal muscles occurs in chronic 
lead-poisoning, the substances being usually hydroxid of 
lead, lead oxid, and red peroxid of lead (Mennige). To 

^ Compare Seifert, " Die Gewerbekrankheiten," etc. 

2 " Die Krankheiten der Nerven." ^ " Arch. f. Laryng.," vol. iv. 



246 INTOXICATIONS. 

judge by the numerous descriptions, the clinical picture 
varies a good deal, and there is no typical form for the 
paralysis. Seifert, Schech, Krause, and P. Heymann have 
described paralysis of various muscles, including the ad- 
ductors and abductors. We have individual palsies of the 
cricoarytenoideus lateralis, and of the interarytenoideus ; 
unilateral and bilateral paralysis of the posticus and of the 
recurrent laryngeal nerve ; and we can not agree with M. 
Mackenzie when he says that the " adductors only are 
implicated, just as in cases of systemic lead-poisoning the 
extensors are exclusively affected." Krause mentions a 
peculiar form of phonatory disturbance, an intention tremor, 
as a result of lead-poisoning. The prognosis is favorable. 
The three cases observed by Heymann all ended in recovery 
after the customary treatment for lead-poisoning. 

In the ear the effects of lead-poisoning have been described 
as tinnitus aurium and a gradual deterioration in the power 
of hearing. Wolf ^ reports several cases in which the degree 
and kind of deafness were variable, so that the functional 
test sometimes appeared to locate the seat of the disease in 
the middle ear, at others in the internal ear. In one of 
Wolf's cases, in which the onset was acute, he assumes an 
acute exudation into the cochlea which underwent absorp- 
tion after treatment, and thus allowed the function to be 
restored. We may assume a neuritis of the auditory nerve 
analogous to that which occurs in other cranial nerves, such 
as the vagus and the optic nerve, without, however, neglect- 
ing theetiologic importance of the arteriosclerotic condition 
of the vessels which accompanies the intoxication. ^ 

Mercurial poisoning is well known under the name of 
" ptyalism," and affects the mucous membrane of the mouth 
and pharynx, while, as far as we know, the nose and larynx 
escape. Von Jaksch ^ describes a case of acute sublimate 
poisoning following the ingestion of a teaspoonful of the 
drug. The mucous membrane of the uvula, the pharynx, 
the epiglottis, and the aryepiglottic folds were greatly swollen 
and covered with a whitish exudate, while the vocal cords 
were only slightly inflamed. On the fourteenth day after 
the accident ulcers were found in these regions, the swell- 
ing had subsided, and at the autopsy, which was held on 

1 " Verhandl. der D. otol. Gesellsch.," 1S95. 

2 Compare Ebstein, " D. Arch. f. klin. Med.," LVIII, p. i. 

3 " Nothnagel's Handb.," vol. I, p. 220. 



COPPER, PHOSPHORUS, ETC. 247 

the twenty-fifth day, deep ulcers were found, some of them 
partly healed. 

Mercury is said to have the same effect as lead on the 
sound-perceiving apparatus of the ear. 

Copper, antimony, and phosphorus are said to produce 
hoarseness, but the manner of its production is nowhere 
indicated. Hemorrhages into the pharyngeal structures, 
especially the tonsils, have been observed in phosphorus- 
poisoning. 

Copper and phosphorus, as they are used in the arts, may 
set up acute rhinitis and effect alterations in the septum 
analogous to those produced by chromic acid (Seifert). 

In a case of poisoning by silver nitrate in a man who 
worked with the substance in a glass pearl factory, v. 
Jakscli found patches of bluish-black pigmentation on the 
external skin, on the mucous membrane of the mouth and 
tongue, on the drum membrane, and on the laryngeal 
mucous membrane. 

The medicinal use of compounds belonging to the aro- 
matic series is often followed by disturbances in the auditory 
sphere, even when the maximum dose is not exceeded. The 
upper air-passages usually escape. In a very few cases 
erythema (quinin, antipyrin, and saHcylic acid), pemphigoid 
eruptions (antipyrin 2), or hemorrhages were found on the 
mucous membrane of the pharynx as on the ejcternal skin. 
(We find no mention of the larynx in this connection.) 

We may mention a few very unusual observations, such as 
a case, reported by Ebstein,^ of intoxication in an employee 
of a salicylic acid factory, in which, in addition to marked 
pharyngitis, there was edematous swelling about the vocal 
processes and in the trachea ; Hilbert * remarks that after 
the use of antipyrin and antifebrin he has observed the 
occurrence of parosmia consisting in the smelling of aro- 
matic flavors, such as cinnamon ; and, finally, the occurrence 
of an acute edematous angina after the use of salol — a 
statement for which Lavallee ^ is responsible. 

In strychnin-poisoning there is marked hyperesthesia of 
the auditory nerve, which may, under the influence of an 
auditory impression, lead to general convulsions. 

^ Nothnagel's " Spec. Path. u. Therap.," vol. I, p. 240. 

2 Veil, "Arch. f. Derm. u. Syph. ," 189I, p. 33. 

3 " Wien. klin. Wochen.," 1896, No. 11. 
■1 See " Semon's Centralbl.," viir, p. 558. 
5 See " Semon's Centralbl.," viii, p. 3S0. 



248 INTOXICATIONS. 

Quinin, salicylic acid, and antipyrin give rise to tinnitus 
aurium and difficult hearing. The toxic effect of the two 
first-named substances is generally recognized, and has 
been studied experimentally ; we possess investigations by 
Weber- Lie 1 and his followers as well as by Kirchner which 
establish beyond a doubt the occurrence of clinical and 
anatomic disturbances in the organ of hearing. According 
to these investigations, the effect of quinin and salicylic 
acid are very much the same, except that the disturbances 
after excessive use of salicylic acid are more violent and 
somewhat more persistent. The administration of i gm. 
of muriate of quinin and from 4.5 to 5 gm. of sodium 
salicylate was followed after from one to one and one- 
half, and from two and one-half to four hours respec- 
tively, by various subjective noises in the ear, which had 
completely disappeared twelve hours later ; while after the 
use of salicylic acid the subjective symptoms lasted several 
days. The effect on the hearing occurred somewhat later 
than the tinnitus aurium, and always lasted longer, but after 
salicylic acid it persisted for several months. ^ We learn 
something of the way in which the auditory disturbance is 
produced by Kirchner's experiments on animals ; after 
giving quinin (i.o) and sodium salicylate (2.0), he found 
ecchymoses in the mucous membrane of the tympanic 
cavity and of the vestibule, showing that the phenomenon 
is due to a disturbance of blood pressure, and not to a 
direct toxic effect on the organ of hearing. In view of the 
possibility of extravasations occurring in the labyrinth, 
where absorption is imperfect and the functional disturb- 
ances which result are therefore lasting, the greatest caution 
is indicated in prescribing this remedy for persons who 
have ever been subject to ear disease; Weber- Liel found 
that the impairment of hearing which follows the use of 
these remedies lasts much longer, and may even become 
permanent, in persons subject to ear disease. 

Poisoning with sausage and fish, due to the presence of 
ptomains containing a number of alkaloid bodies, produces 
dryness of the mucous membrane and hoarseness similar 
to that observed in atropin-poisoning. According to v. 
Jaksch, there may be symptoms of bulbar paralysis and 
pharyngeal and laryngeal palsies, but unfortunately we 

1 Weber- Liel, " Mon. f. Olir.," 1SS2, p. 7. 



CHLOROFORM, TOBACCO, ALCOHOL. 249 

have no laryngoscopic findings, and Stuffer remarks on the 
difference of opinion as to the occurrence of hoarseness in 
fish-poisoning. 

It has been said by Moos and Hackley that chloroform 
narcosis may be accompanied by deafness, tinnitus aurium, 
and double hearing, and Haug reports having seen such 
disturbances very frequently. But as the tinnitus aurium, 
paracousis, and auditory hallucinations can be attributed to 
the narcosis, Haug's statement — especially with regard to 
auditory hyperesthesia, which " may persist for several 
hours or even several days after the narcosis," and with 
regard to double hearing — can not be accepted unreservedly 
in the absence of positive case histories. It appears to be 
true that a progressive diminution in the power of hearing 
occasionally follows narcosis, particularly after the patient 
has been repeatedly subjected to an anesthetic, but the etio- 
logic factor concerned is very difficult of interpretation. I 
have often seen patients, particularly women, gradually 
develop a slowly increasing deafness, which is usually 
attributed to chronic middle-ear catarrh, several decads 
after they have undergone chloroform narcosis ; but we 
should accord to the imagination of our patients a fatal in- 
fluence on our science if we allowed such statements to pass 
as current. 

Finally, we may mention the intoxications that follow the 
abuse of tobacco and alcohol. Here we have to deal both 
with a local irritant effect on the mucous membranes of the 
upper air-passages and with the general toxic effect on the 
system. The catarrh of the smoker and the alcoholic has 
become proverbial. We have all had ample opportunity 
to convince ourselves of its occurrence, and there can be 
no doubt on the subject. The question Avhether the com- 
bustion products which are mixed with the smoke or a spe- 
cific quality inherent in the vegetable poison — of Avhich 
nicotin is usually considered the prototype — is responsible 
for this irritation of the mucous membrane may perhaps 
find its answer in the results of investigations conducted on 
chewers and snuff takers, in whom, except for the mechan- 
ical irritation, the effect on the mucous membrane bears no 
proportion as to intensity and extension of the process to 
that observed in smokers, in spite of the fact that the 
tobacco is much more thoroughly and completely absorbed. 
Analocrous to the extensive lar\'nc[-eal catarrh, we have 



250 INTOXICATIONS. 

catarrh of the tubes, with its consequences to the middle 
ear in the form of catarrhal otitis media, which offers the 
best explanation for the chronic hardness of hearing so fre- 
quently observed in smokers, and which usually presents 
the character of a simple middle-ear catarrh. The possi- 
bility of a chronic neuritis of the auditory nerve analogous 
to tobacco amblyopia, which Moss assumes to be the cause 
of the difficult hearing and tinnitus aurium, can not be 
denied ; but, so far, we have no proof of its occurrence. 

The effect of alcohol on the organ of hearing is well 
known. It leads to tinnitus aurium and difficult hearing 
of a progressive character. The chief etiologic factor 
given is chronic middle -ear catarrh secondary to chronic 
pharyngitis ; in addition to which the effect of the alcohol 
on the vascular system and its stimulating psychic effect 
no doubt play an important part in the production of tin- 
nitus aurium and hallucinations. 

Hoarseness has been mentioned as a symptom of acute 
alcoholic poisoning, but since alcoholic paralysis of the re- 
current nerve has never been described, it must be regarded 
as the result of a disturbance of coordination due to the 
intoxication. 

Alt 1 had occasion to observe alcoholic neuritis of the 
auditory nerve in a case of alcoholic multiple neuritis. 

In conclusion, I wish to add a caution in regard to the 
use of irritating and astringent remedies in the treatment 
of the nose, as such substances, especially when used in the 
form of a douche or a powder, are very likely to pro- 
duce disturbance of the sense of smell. In this respect 
the zinc salts, alum, tannin, and carbolic acid are particu- 
larly dangerous, and should be absolutely avoided in the 
treatment of the nose. 

1 "Mon. f. Ohr.," 1897, p. 171. 



XII. NERVOUS DISEASES. 



U GENERAL REMARKS ON DISEASES OF THE 
LARYNX IN DISEASES OF THE CENTRAL 
NERVOUS SYSTEM. 

DISEASES OF THE SENSORY AND MOTOR NERVES OF 
THE LARYNX. 

The disturbances which may occur in the larynx as a 
result of disease of the central nervous system are both 
sensory and motor. The pneumogastric nerve supplies 
the larynx with sensory fibers through the superior laryn- 
geal nerve and its internal branch, which is distributed to 
the mucous membrane of the base of the tongue, the epi- 
glottis, the pyriform sinuses, and the entire interior of the 
larynx ; hence, disease of the sensory nuclei and roots of 
the pneumogastric may produce sensory disturbances in 
the form of anesthesia, paresthesia, and hyperesthesia. 
These are most frequent in bulbar disease and in diseases 
affecting the trunk of the vagus, and are therefore of great 
importance for the diagnosis of these conditions. They 
have also been occasionally observed in hemiplegia, in 
cerebral focal diseases, and in progressive paralysis, but 
have only a historic interest in this connection. 

The motor disturbances in the larynx manifest them- 
selves as irritative motor phenomena, as disturbances of 
coordination, and as palsies. The irritative phenomena 
occur in the form of tonic spasms, which are designated 
spasm of the glottis, laryngeal crises, and ictus laryngis ; 
or in the form of clonic spasms, as rhythmic twitchings 
and tremors or atactic movements of the vocal cords, such 
as are sometimes observed in cases of brain tumor, cerebral 
abscess, and meningitis, and particularly in multiple scle- 
rosis, in bulbar paralysis, and in a great number of neu- 
roses. 

Paralysis may occur either in the groups of muscles sup- 
251 



252 NERVOUS DISEASES. 

plied by the superior laryngeal or in those supplied by the 
inferior laryngeal or recurrent nerve. The superior laryn- 
geal nerve, through its external motor branch, supplies the 
cricothyroideus muscles, whose function it is to make tense 
the vocal cords. Paralysis of this muscle, which manifests 
itself in roughness of the voice and sagging of the vocal 
cord on the paralyzed side during phonation, and by a 
slight waviness of the free border of the vocal cord, occurs 
very rarely as the result of an isolated paralysis of the ex- 
ternal branch of the superior laryngeal nerve, and is never 
the result of a central lesion. When a paralysis of the 
cricothyroid muscles occurs in connection with a general 
paralysis of the motor fibers of the pneumogastric, either 
of central or peripheral origin, involving both the inferior 
and superior laryngeal nerves, it becomes merged in the 
general picture of complete paralysis of the vocal cords, 
and can not be distinguished clinically from that of par- 
alysis of the recurrent nerve alone. 

Paralysis of the recurrent nerve is by far the most im- 
portant from a diagnostic point of view, for it is the typical 
symptom of a lesion of the motor paths in the central ner- 
vous system, whenever peripheral disease of the nerves or 
injury to the nerve-trunk can be excluded. As the ques- 
tion of paralysis of the recurrent nerve, its origin, and the 
interpretation of the laryngoscopic image which it pro- 
duces has been and still is the subject of numerous contro- 
versies, it may not be out of place to present the present 
state of the question of paralysis of the recurrent nerve. 

The muscles of the larynx that exert any influence on 
the movements of the vocal cords are divided into three 
groups, named, respectively, the openers, closers, and ten- 
sors of the rima glottidis. Opening of the glottis is 
effected by the crico-arytenoideus posticus drawing the 
muscular process of the arytenoid cartilage to which it is 
attached inward and at the same time rotating the vocal 
process outward. Closure of the glottis is accomplished 
by the combined action of various muscles which together 
make up a muscular ring embracing the entire glottis. 
Each one of these small muscles has its peculiar action, 
and the cooperation of all is required to effect exact ap- 
proximation of the vocal cords. Finally, there is a third 
group of muscles, which connects the cricoid with the thy- 
roid cartilage, and whose function it is to stretch the vocal 



PARALYSIS OF THE RECURRENT NERVE. 253 

cord by increasing the distance between the vocal process 
and the anterior angle of the thyroid cartilage. As the 
resulting posterior displacement of the plate of the cricoid 
cartilage is accompanied by depression, the vocal cord, 
when stretched in this way, occupies a deeper position. 

These three groups of muscles are supplied by the infe- 
rior, or recurrent, and the superior laryngeal nerve. Now, 
it is a remarkable fact that the openers and closers of the 
glottis, although mutually antagonistic, are both supplied 
by the inferior laryngeal nerve, while the motor branch of 
the superior nerve exclusively supplies the tensor mus- 
cles. It follows that any sudden injury to the inferior 
laryngeal nerve affects the openers and closers equally, so 
that the vocal cord, in the absence of antagonistic muscular 
traction, assumes a position of equihbrium — a position, in 
short, which is designated "the pathologic cadaveric posi- 
tion." The term " cadaveric position " was first used by 
v. Ziemssen, because it was found that the position of the 
vocal cords postmortem was the same as that seen in 
paralysis of the recurrent nerves. In both cases the vocal 
cords assume a position midway between inspiration and 
expiration. In recent times it has been repeatedly pointed 
out that the width of the glottis is not exactly the same in 
both cases, and that in the pathologic cadaveric position 
due to paralysis of the recurrent the vocal cords are slightly 
more adducted than in the so-called genuine cadaveric 
position, as seen in the dead body. This variation is to be 
attributed to the action of the crico-thyroid muscles, which 
are not affected by paralysis of the recurrent nerves, as 
they receive their innervation from the superior laryngeal, 
and can therefore continue to act in a peripheral palsy of 
the recurrent nerves. We know that the action of these 
muscles consists in stretching the vocal cords and at the 
same time in slightly approximating the edges of the vocal 
cords to the median line. This phenomenon is found to 
be retained in the pathologic cadaveric position, and ex- 
plains the difference between the two kinds of cadaveric 
position. How the function of the cricothyroid muscle is 
affected in central palsies is not known, but it is probable 
that its motor nerve has the same origin as the other nerves, 
so that it must be held to be involved in any central par- 
alysis of the vocal cords. 

In addition to this complete paral\-sis of the recurrent 



2 54 NERVOUS DISEASES. 

nerve, which affects the adductors and abductors equally, 
there is another important form of paralysis affecting this 
nerve, which is dQS\gr\?Lt&6. posticus paralysis. In the laryn- 
goscopic image the vocal cord is seen to be immovably 
fixed in the median line, while the free border is taut, 
instead of concave, as in paralysis of the recurrent, so that 
phonation remains normal. This median position is ex- 
plained by the failure of the abductors, and the condition is 
therefore designated posticus paralysis. It is this posticus 
paralysis that has given rise to so many controversies, which 
have again been revived in recent times, and are still very 
active. In order to understand the question thoroughly we 
must premise Semon's proposition, which says : " In organic 
progressive diseases of the roots and trunks of the spinal 
accessory, pneumogastric, and recurrent nerves the dilator 
fibers are affected earlier than the constrictor fibers, or may 
even be attacked exclusively." Applied to actual practice, 
this means that in such progressive diseases of the recur- 
rent nerve we have first a paralysis of the posticus, and later 
paralysis of the adductors of the vocal cord, such as have 
just been described as total paralysis of the recurrent nerve. 
The correctness of this law, which is known as Semon's 
law, has been subjected to a rigorous test by Semon him- 
self. He first formulated it on the basis of a series of 
chnical cases, and has since confirmed it in various publica- 
tions by adducing physiologic and etiologic facts in its sup- 
port. But in spite of these positive proofs the law has not 
been accepted, and many animated controversies have taken 
place between Semon and his followers on the one hand, 
and his opponents on the other, I am forced to go into 
this matter in some detail, as an exact understanding of the 
entire question is necessary in the criticism of the volumi- 
nous literature which has appeared on the subject. The 
question of this primary posticus paralysis of Semon's is 
important, because it enables us approximately to judge of 
the duration of a paralysis by observing whether the affected 
vocal cord is in the median or in the cadaveric position, and 
because it is a sign that the primary disease is progressing 
if the posticus paralysis, in spite of treatment, goes on to 
complete paralysis of the recurrent nerve. 

I shall divide this discussion of the median position of 
the paralyzed vocal cord which has been designated as 
posticus paralysis into two sections ; for, in the first place, 



PARALYSIS OF THE RECURRENT NERVE. 255 

the question must be settled whether a median position of 
the vocal cord necessarily means that there is an isolated 
paralysis of the crico-arytenoideus posticus, and, in the 
second place, we must attempt to explain how, when the 
fibers that supply the antagonistic muscles are contained in 
the same nerve-trunk, those which innervate the crico-ary- 
tenoideus posticus can be for years the only ones affected 
by the paralysis. 

According to Krause, who bases his opinion on experi- 
mental investigation, a median position of the vocal cord 
may, under certain conditions, not as yet very well ex- 
plained, be due to reflex contraction of the laryngeal 
muscles. Krause experimented on animals by slowly con- 
stricting the recurrent nerve under proper precautions, and 
observed that a median position very soon appeared, which 
after about twenty-four hours changed to the cadaveric 
position. He accordingly adopts the theory, which he 
explains with much ingenuity, that the gradually increasing 
irritation of the nerve first gives rise to a reflex contraction, 
which first manifests itself in a median position of the vocal 
cord, because the adductors surpass all the other muscles 
in bulk, but which finally goes on to the cadaveric position 
when the nerve is completely paralyzed. 

The promulgation of this theory, which is accepted by 
various authors, was followed by another, recently advanced 
by Grossman, to the effect that total paralysis of the recur- 
rent is not a. cadaveric position, as is generally supposed, but 
rather a position of adduction near the middle line, which 
practically (Grossman is not very clear on this point) cor- 
responds to the median position. The final cadaveric posi- 
tion is, according to him, the expression of an additional 
paralysis of the cricothyroid muscle, the occurrence of 
which he explains as the result of secondary atrophy of 
the antagonistic adductor muscles, due to disuse in conse- 
quence of the paralysis. 

Although at first sight both Krause's and Grossman's 
hypotheses may appear plausible, they will not bear the 
test of careful examination, and are in direct contradiction 
to a great number of clinical and experimental facts. To 
give all my reasons for this difference of opinion would lead 
me too far astray, but I will mention a few facts of pathologic 
anatomy which are insisted on by various authors : As 
against Krause's hypothesis we ha\'e many cases in which 



256 NERVOUS DISEASES. 

the picture of a posticus paralysis was seen in vivo, and 
where, after death, only the crico-arytenoideus posticus 
presented an atrophy which was too pronounced to be 
reconciled with the theory of muscular contraction, in 
view of the long duration of the posticus paralysis and 
the integrity of the adductor muscles. 

In refutation of Grossman's hypothesis we have, in ad- 
dition to many other considerations, the anatomic fact that 
it has so far been impossible to demonstrate positively the 
occurrence of atrophy of the cricothyroids in a simple par- 
alysis of the recurrent nerve, where the superior laryngeal 
was positively excluded — a condition which is absolutely 
necessary to demonstrate atrophy due to disuse, as claimed 
by Grossman. 

I therefore assume that I have disposed of these objec- 
tions, and that in the form known as posticus paralysis we 
have actually to deal with an isolated paralysis of the crico- 
arytenoideus posticus muscle. As, therefore, paralysis of 
the abductors is the first sign of a slowly progressing injury 
to the recurrent nerve, we are confronted with the most in- 
explicable phenomenon when we consider that this nerve 
innervates not only the paralyzed muscle, but also its 
antagonists, the adductors. Hence, the discussion is prac- 
tically narrowed down to the question as to why the dilators 
become paralyzed before the closers, in spite of the fact that 
both are supplied by the same nerve. 

The explanation that the fibers destined for the posticus 
muscle are more superficial than those which supply the 
adductors can not be taken seriously, but I may mention 
the attempted explanation, whicl? is based on Exner's ex- 
periments on animals. Exner and his disciples have de- 
voted much study to the innervation of the larynx, and have 
found certain individual variations ; most muscles appear to 
have a double innervation, either the corresponding nerves 
on both sides or several nerves of the same side being con- 
cerned in the innervation of one muscle. If this condition 
occurred regularly in man, we should naturally be led to 
conclude that in cases of isolated paralysis of the posticus, 
although there is a total paralysis of the recurrent fibers, 
the paralysis affects only the dilators, because in such a case 
the adductors derive an additional supply from another 
nerve. Unfortunately, this hypothesis is contradicted by a 
great number of clinical observations, as we have absolutely 



PARALYSIS OF THE RECURRENT NERVE. 25/ 

no proof of individual variation in the form of a double in- 
nervation ; besides, many of Exner's experiments are 
wanting in clearness, and other experimenters have not been 
able to confirm his results. 

I recently, for a different purpose, practised extirpation 
of the various laryngeal nerves in rabbits, and in every case 
I observed atrophy of the abductors and adductors after 
division of the recurrent nerve, so that I am forced to ex- 
clude the existence of a double innervation for these cases. 
On the other hand, in a series of experiments which go to 
prove that there is a physiologic difference in the biologic 
relations of the two groups of muscles, we have exact and 
incontestible proofs of the greater vulnerability of the dila- 
tors, which might be responsible for a primary paralysis of 
the postici. It is proved by one series of experiments that 
the electric irritability of the posticus muscle disappears long 
before that of the adductors, and this condition is found not 
only postmortem, but also in ether anesthesia and when the 
nerve is gradually allowed to freeze. In this connection it 
is important to remember Grabower's discovery that the 
nerve-endings in the abductors differ morphologically from 
those in the adductors. From this we may conclude that 
the adductors and abductors are not ordinary antagonists, 
like the extensors and flexors of the extremities, and we 
must try to find some cause for their physiologic difference. 
This difference is found in their function, since the adduct- 
ors of the vocal cords are concerned in phonation, while the 
abductors merely represent respiratory muscles. Corre- 
sponding to these different functions there must be different 
kinds of fibers in the recurrent nerve, some of which are in- 
tended for phonation while others transmit reflex impulses 
connected with respiration. 

The question whether the action of the crico-arytenoideus 
posticus is exclusively a reflex action has been carefully 
studied by Semon and Horsley. These authors found that 
the ordinary respiratory position in which the glottis gapes 
wider than in the cadaveric position must be regarded as a 
reflex tonic spasm, which is constantly present in the posti- 
cus muscle under the influence of the respiratory center, its 
object being to keep the glottis sufficiently dilated for the 
act of respiration. The existence of such a reflex tonic 
spasm in the nerve-fibers destined for the posticus would 
serve to explain the physiologic fact previously mentioned, 
17 



258 NERVOUS DISEASES. 

that the abductors of the vocal cords become fatigued 
earlier than the adductors, since on this supposition we have 
to deal with two kinds of nerves in the recurrent — afferent 
and efferent nerves. The afferent nerves produce reflex 
tonic spasm in the posticus muscle, while the efferent nerves 
act as simple motor nerves to the adductors. Thus, the 
early and isolated appearance of paralysis of the posticus is 
best explained by the physiologic law that the irritability 
of afferent nerves is exhausted earlier than that of efferent 
nerves. 

To sum up, we have learned that there are two kinds of 
paralysis of the recurrent nerve ; the first stage of a lesion 
to the recurrent nerve gives rise to posticus paralysis, while 
a fully developed recurrent paralysis finds expression in the 
so-called pathologic cadaveric position. We have left to 
consider only the mode of transition from one form to the 
other, and we learn from clinical observation that this 
takes place in a typical manner. The first step in the 
progress of the paralysis consists in a relaxation of the free 
border of the vocal cord, which was tightly stretched in 
the simple posticus paralysis. The border becomes con- 
cave toward the median line, then gradually bows outward, 
and finally goes on to recurrent paralysis. If recovery 
takes place in a recurrent paralysis, as I saw lately in a 
capital case of postdiphtheric paralysis, the vocal cord first 
moves into the median position, and for a short time pre- 
sents the picture of a posticus paralysis, before it regains its 
normal movability. 

THE LOCALIZATION OF CENTERS FOR THE MOVEMENT 
OF THE VOCAL CORDS IN THE CENTRAL NERVOUS 
SYSTEM, AND THE EFFECT OF DISEASES OF THE CEN- 
TRAL NERVOUS SYSTEM. 

Hemorrhages, foci of softening, pseudobulbar paralysis, 
sclerotic foci, tumors, tubercular and syphilitic tumors, and 
cerebral abscesses may produce paralysis of the vocal cords 
when the lesion is situated in the central motor paths for voice 
production and for the movements of the vocal cords. The 
localization of movements of the vocal cords in the cere- 
brum is still a matter of dispute, so that the diagnostic 
value of paralysis of the vocal cords for the localization of 
such diseases is limited. 

The number of cases of which we possess a clinical and 



LOCALIZATION OF LARYNGEAL MOVEMENTS. 259 

anatomic description is too small to afford a basis for a 
definite symptomatology of laryngeal disturbances in dis- 
eases of the central nervous system, and if I were to take 
up the various brain diseases individually, my description 
would be nothing more than an incoherent series of facts re- 
peated from the literature. I shall therefore content myself 
with a short presentation of the views which prevail at the 
present time in regard to the localization of laryngeal 
movements in the central nervous system. This will form 
a basis in any given case for deducting the site of the 
morbid focus from the existing disturbances in the larynx. 

The motor paths for the larynx in the medulla oblongata 
are better known than those in the cerebrum. The nuclei 
become typically involved in certain systemic diseases, and 
sensory as well as motor disturbances of the larynx result. 
But even in this region, although the question in the main 
is fairly well settled, there are certain points which are still 
under dispute, the most important one of which is whether 
the nucleus of the motor nerves of the larynx is to be 
found in the vagus or in the spinal accessory. After we 
have given a general description of the localization of the 
larynx in the cerebrum and its relation to the medulla 
oblongata, it will be necessary to discuss a few diseases of 
the spinal cord which give rise to typical disturbances in the 
larynx as a part of their general symptom-complex. 

The motor nerves of the larynx are the superior and 
inferior (or recurrent) laryngeal nerves — branches of the 
vagus. The trunk of the vagus, therefore, contains the 
peripheral paths which transmit nerve impulses to the vocal 
cords and cause them to open or to close the rima glottidis 
in the service of the phonatory and respiratory function of 
the larynx. As the larynx has a double function — that of 
phonation, which is purely motor and is dependent on the 
will, and that of respiration, which consists in the reflex 
opening of the glottis under the influence of the respiratory 
center — there must be two different centers for adduction 
and abduction in the central nervous system. For the 
voluntary movements performed during speech we must 
assume, in addition to the center in the medulla oblongata, 
a second center in the cortex, while the reflex opening of 
the glottis during respiration, which takes place independ- 
ently of the will, is probably but little, if at all, under the 
influence of the cortical center. 



26o NERVOUS DISEASES. 

We emphasize this point because an impression has 
lately gone abroad that the vocal cords can be voluntarily 
adducted or abducted on one side. This view accords 
with the conception of a bilateral symmetric movement 
only so far as respiration is not altogether reflex, but partly 
subject to the will, since we are able to make deep volun- 
tary inspirations and thereby effect a wide gaping of the 
rima glottidis. We learn from experimental investigations 
and from pathology that the assumption of two separate 
centers for the two kinds of movement is necessary to 
explain the occurrence of the different kinds of paralysis. 

It must be admitted at the outset, however, that the 
discussion is only in its infancy, and that, owing to the 
contradictory statements and findings of careful observers 
and experimenters, it is impossible to give a clear objective 
presentation of the state of affairs, so that in attempting to 
explain the various phenomena which present themselves 
we are often forced to resort to hypotheses to bridge the 
gaps in our argument. 

Even the question of the origin of the motor nerves of 
the larynx is not definitely settled. The controversy as to 
whether the nucleus of the vagus or that of the spinal 
accessory, or both together, represents their origin has 
been going on for several decads, and has been lately 
rekindled by Grabower's investigation, just as the authori- 
ties were beginning to incline to the opinion that the motor 
fibers for the larynx were derived from the nucleus of the 
spinal accessory. 

Grabower has proved by a series of sections through the 
medulla oblongata and the spinal cord that the spinal acces- 
sory is a purely spinal nerve ; its nucleus and deep roots 
have no relation to the nucleus of the vagus. According 
to him, the ventral nucleus of the vagus (the nucleus 
ambiguus) represents the origin of the motor nerves of the 
larynx. In a detailed discussion of this question Semon ^ 
says that his clinical experiences have been such that he can 
not agree with Grabower's opinions, because he is unable 
to reconcile them with certain observed cases of simulta- 
neous paralysis of the vocal cords and of the trapezius and 
sternocleidomastoid muscles, which are supplied by the 
spinal accessory nerve. But Grabower ^ himself denies 

^ Heymann's " Handb. d. Laryng.," vol. I, p. 606. 
2" Arch. f. Laryng.," vol. v. 



BULBAR AND CORTICAL PARALYSES. 26 1 

that those cases in which there is a simultaneous paralysis 
of the larynx and of the spinal accessory are any proof that 
these various groups of muscles are under the control of a 
common nucleus. Hence, we have to regard the question 
as still undecided for the present. We may mention that 
Claude Bernard has advanced the opinion that the spinal 
accessory represents the nerve of phonation, and the vagus 
the nerve of respiration. 

While the occurrence of bulbar paralysis in the larynx, 
in diseases which affect the bulbar nuclei, is definitely estab- 
lished, the question whether cortical paralysis of the larynx 
ever occurs is still undecided. It is known that Krause 
found a spot on the anterior lower extremity of the anterior 
central convolution, immediately behind the precentral 
fissure, — called after him, " Krause's center," — irritation of 
which on one side of the brain produces a bilateral adduc- 
tion of the vocal cords. It follows, therefore, that each of 
these two cortical centers for adduction is capable of influ- 
encing the movements of both vocal cords ; but, on the 
other hand, unilateral lesion of this cortical region is not 
capable of suspending movement in the larynx, as has been 
shown by extirpation of these parts. In view of the great 
frequency of apoplexy and of other lesions in this region of 
the cortex, the literature ought to contain a great number 
of cortical palsies, but, as a matter of fact, we possess only 
a very small number of observations, ^ which can not even 
be definitely referred to a unilateral cerebral injury, because 
no autopsies are given and the clinical history is not quite 
clear. On the other hand, when the centers on both sides 
of the cerebrum are diseased, cortical palsy undoubtedly 
results, as was proved by Semon,^ both by experiments on 
animals and by two cases where the diagnosis was con- 
firmed by an autopsy. 

In syphilis, tuberculosis, multiple sclerosis, and menin- 
gitis, and in tumors and hemorrhages, we should therefore 
expect a cortical palsy, affecting both vocal cords, due to 
injury of both Krause's centers. 

A great number of theories, more or less well supported 
by experiments on animals, have been presented on this 
subject, while clinical observations, on the other hand, are 

' Cases bearing on this question will be found quoted by Onodi, "Rev. 
hebd. de laryng.," etc., 1898, No. 4. 

2 Heymann's " Handb. der Laryng.," i, pp. 692 and 701. 



262 NERVOUS DISEASES. 

very meager. If all these observations were perfectly 
clear there would be no controversy, but as some authors 
claim to have seen a crossed unilateral cortical paralysis of 
the vocal cords, while others absolutely deny that any but a 
bilateral cortical lesion is capable of producing a double 
paralysis of the vocal cords, there is evidently room for a 
great deal of discussion, and any contributions, such as 
those which have lately been added by Uchermann,^ are 
well worthy of attention. In connection with a case of 
right-sided hemiplegia, motor aphasia, and paralysis of the 
adductors in the larynx, he raises the question whether a 
one-sided — that is to say, left-sided — injury of the phona- 
tion center is capable of producing a double palsy of the 
adductors, and suggests the possibility that the center of 
phonation, like that of speech, is usually located on one 
side. Injury of the fibers which pass through the internal 
capsule from the cortex to the medulla oblongata neces- 
sarily produces the same effect as a cortical lesion. 

The existence of a center of phonation in the posterior 
corpora quadrigemina, and the corresponding area in the 
floor of the fourth ventricle, capable of producing approxi- 
mation of the vocal cords, even after communication with 
the cortex has been interrupted, is maintained by Onodi, and 
denied by Klemperer and Grabower. 

According to Semon and Horsley, abduction of the vocal 
cords or opening of the rima glottidis is under the control 
of two different regions in the medulla oblongata : One 
of these is situated in the ala cinerea ; the other, in the 
region of the origin of the auditory nerve, extending to the 
mouth of the aqueduct of Sylvius. Irritation of these 
regions was always followed by bilateral abduction of the 
vocal cords. 

1 "Arch. f. Laryng. u. Rhinol.," p. 332. 



FUNCTIONAL DISTURBANCES IN THE EAR. 263 

2, GENERAL REMARKS ON THE AURAL DIS- 
TURBANCES PRODUCED IN DISEASES OF THE 
CENTRAL NERVOUS SYSTEM, 

THE MECHANISM OF FUNCTIONAL DISTURBANCES IN 

THE EAR AND THE ELECTRIC REACTIONS OF THE 

AUDITORY NERVE. 

The functional disturbances produced in the organ of 
hearing by disease in the central nervous system consist in 
disturbances of the hearing or in the equilibrium, according 
as the paths of the cochlear or those of the vestibular 
nerves are involved. When the trunk of the auditory nerve 
is diseased, both hearing and equilibrium are affected. 
Nervous disturbances of the hearing in central disease mani- 
fest themselves either in abnormal excitability of the audi- 
tory nerve, which may be so intense that the perception of 
certain tones becomes positively painful, or in torpor of the 
nerve, which, again, may go on to complete insensibility to 
auditory impressions. This form of deafness is accompanied 
by certain characteristic pathologic alterations in the ear 
which enable us to distinguish it from those disturbances 
having their seat in the sound-conducting apparatus. The 
hearing in such cases is lost for certain tones, so that in 
testing the field of hearing one is forced to use a long series 
of graduated tuning-forks. The tuning-fork test is intended 
to determine the power of the auditory nerves to perceive 
tones which reach the internal ear through the air or 
through the craniotympanic conducting path. If cranio- 
tympanic conduction is very much weakened or entirely 
absent, it is a sign of nervous disease. 

Tinnitus aurium is the first symptom observed in disease 
of the auditory nerve paths. In the first stage of a disease 
in the central nervous system it may be the expression of 
irritability of the auditory nerve, but it may also occur in 
the later periods, in which the irritability of the nervous 
paths is entirely lost. These subjective noises present cer- 
tain characteristic qualities, which serve to distinguish them 
from those produced in the middle ear ; they may be con- 
tinuous and low in pitch, and so intense as to be compared 
with the thunder of cannon or the din of a railroad train ; 
they may be high-pitched and musical ; the tinnitus aurium 
may have a register or pitch of C'* to C^ ; or it may be a 



264 NERVOUS DISEASES. 

musical or harmonious sound described as a melody, the 
ringing of bells, or the twittering of birds. 

Finally, we have the disturbances of equilibrium which 
are regarded as the expression of disease of the vestibular 
nerve, and which are often associated with nausea and 
vomiting. 

These three symptoms are described together under the 
name of Meniere's symptom-complex. Before the purely 
symptomatic nature of these phenomena — which are com- 
mon to all diseases of the auditory nerve paths — was appre- 
ciated, it was customary to speak of a Meniere's disease, 
because Meniere had first observed these symptoms in a 
case of sudden hemorrhage from the labyrinth. Since the 
appearance of v. Frankel Hockwart's ^ publication, in which 
he presents this Meniere's symptom-complex in its true 
light for the benefit of the nonspecialist, it is to be hoped 
that the term Meniere's disease, as applied to the most 
various diseases of the nervous hearing apparatus, will be 
discarded altogether. 

The functional disturbances just described do not enable 
us to determine the exact location of the disease in the 
auditory paths. They are simply diagnostic of a nervous 
disturbance of the hearing, and, so far as our present 
knowledge of these disturbances goes, we are unable to 
determine whether the peripheral terminations of the audi- 
tory nerve in the labyrinth, the nerve-trunk, or the central 
nervous paths are diseased. 

To discuss these symptoms in detail would lead us too 
far into the domain of physiologic research concerning the 
special functions of the individual portions of the ear ; we 
must, however, devote some attention to the electric exami- 
nation of the auditory nerve, which has reached a high 
degree of perfection in the hands of nerve specialists, and is 
now universally used by them as a method of examination, 
while ear specialists even now stand skeptically aloof, just 
as they did thirty years ago, and continue to doubt the 
importance of a method which is insisted on by a great 
number of writers on neurology. 

As the results of electric examination of the auditory 
nerve have been applied in various ways to diseases of the 
central auditory paths, — although it is, as a rule, very 

^ Nothnagel's " Spec. Path. u. Therap.," xi. 



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ELECTRIC REACTION OF AUDITORY NERVE. 265 

imperfectly described or entirely omitted in text-books on 
otology, — I feel impelled to present a general resume of 
the significance of electric reaction of the auditory nei've. 

The attempt has been made to utilize the electric irrita- 
bility of the auditory nerve for purposes of diagnosis and 
therapeutics ; but the results in either direction have not 
been such as to justify the expectations raised by the dog- 
matic teachings of Brenner, published thirty -five years ago 
in his " Elektro-otiatrik." Brenner gives a normal formula 
for the healthy individual as follows : 

Ka. CI R''''. Very loud ringing. 

Ka. D.* R 00 . Ringing persists during continuance of 

current. 

Ka. O Nothing. 

An. CI Nothing. 

An. D Nothing. 

An. O R^ >• Louder ringing, gradually dying away. 

(*During passage of current. ) 

His most important results are embodied in the propo- 
sitions ^ that : " The cathodal contraction produces auditory 
sensation when the circuit is closed, and also during con- 
tinuance of the current, but not when the circuit is opened. 
The anodal contraction gives no reaction either when the 
circuit is closed or during the continuance of the current, 
but does give a reaction when the circuit is opened. The 
anodal reaction ceteris paribus is weaker than the catho- 
dal reaction. The cathodal reaction occurs immediately, 
the anodal reaction only after the current has lasted a cer- 
tain time. After a short duration of the current, opening 
is not followed by a reaction at the cathode. The cathodal 
reaction becomes markedly increased immediately after 
closure, a phenomenon described by the patients as an 
echo, for they frequently remark that the echo is stronger 
than the first (or closing) sound. The reaction persists for 
some time, with a lessened intensity, — ' reverberating 
echo,' — and then completely disappears, although the 
strength of the current remains constant." 

The publication of these statements was, of course, re- 
ceived with equal interest by ear specialists and by neurolo- 
gists, and gave rise to numerous control investigations. 
Schwartze ^ deserves the credit of being the first to find 

i"Virch. Arch.," 28, p. 207. 
2" Arch. f. Ohr.," i, p. 44. 



266 NERVOUS DISEASES. 

flaws in Brenner's formulae, which materially diminished the 
value of the electric reactions for the diagnosis and treat- 
ment of aural diseases. His objections amount to the 
following proposition : That Brenner's normal formula for 
the reaction of a healthy auditory nerve is not by any 
means constant in persons with normal hearing ; that Bren- 
ner's normal formula is given in absolute deafness, which can 
be only due to a disease of the nervous apparatus ; and, 
finally, that, as far as treatment is concerned, the restoration 
of the normal "formula of reaction " has no effect on the 
power of hearing. These objections were answered by 
Brenner ^ and Erb. ^ At first Erb said ^ that "those who 
deny the existence or correctness of Brenner's discoveries 
are simply mistaken," but later he modified his opinion to 
the extent of confirming the first of Schwartze's objections. 
Although opinions in regard to the diagnostic value and 
the production of the reaction are now fairly well settled, 
the skeptical attitude adopted by Schwartze has in the main 
been justified, and the value of " Elektro-otiatrik " is not 
nearly so great to the ear specialist as would appear from 
the statements of neurologists. 

The electric examination is conducted in two different 
ways, called the internal and external methods. The former 
was employed by Brenner, who filled the external auditory 
meatus with water, and then introduced an electrode, with 
certain precautions, ^ so that its extremity was rigidly held 
at a certain distance from the ear-drum and from the walls 
of the meatus. The other electrode was applied to the 
mastoid process, the forehead, the nape of the neck, the 
trunk, or the extremities. The external method introduced 
by Erb is the one now exclusively employed. It consists 
in applying an ordinary flat electrode — the cathode — in 
front of the tragus (taking care not to press on the tragus 
and thereby close the auditory meatus, as this would give 
rise to buzzing and humming noises), while the other elec- 
trode — the anode — is placed on the nape of the neck or the 
palm of the hand. A third method, in which the elec- 
trode is applied to the auditory meatus, filled with water 
(Brenner, Erb), presents no special advantage, while the 

1 " Virch. Arch.," xxxi, p. 483. 

2 "Arch. f. Augen- u. Ohrenheilk.," vol. I, p. 156. 
' "Arch. f. Augen- u. Ohrenheilk.," vol. i, p. 158. 
4 "Virch. Arch.," xxxi, p. 493. 



ELECTRIC REACTION. 26/ 

results of the examination are no more satisfactory when 
one of the electrodes is replaced by a silver wire introduced 
through a tubular catheter into the middle ear, as proposed 
by Wreden.i 

The question has been raised whether the auditory nerve 
or its terminations are really excited by the electric cur- 
rent, or whether what is designated as the reaction of the 
nerve may not be due to the irritation of other structures 
in the ear. It was alleged that the reaction may be pro- 
duced by contraction of the internal muscles of the middle 
ear (Schwartze, Wreden), by irritation of the sympathetic 
(Benedikt), or by a reflex irritation of the auditory through 
the trifacial nerve. While it has long been known that the 
bony labyrinth is a bad electric conductor, the question was 
again discussed by Gartner and Pollak,^ who declared, 
after a series of investigations on pathologic organs, that 
the electric irritability of the auditory nerve depends on 
the excitability of the nerve itself to an electric current and 
on the resistance met with in the ear. 

I have not the space to discuss in detail the various 
arguments which have led to the adoption of the view that 
the condition of the auditory nerve itself determines the 
results of the reaction, without entirely disregarding the 
modification in the resistance due to hyperemic and secretory 
processes ; but in order to elucidate the present status of 
the question, I shall cite the propositions promulgated by 
Gradenigo,^ which most nearly correspond with the results 
of practical experience in the healthy and in the diseased ear. 

1. The normal ear gives an electric reaction of the 
auditory nerve only in exceptional cases and when the 
electric current is unusually strong. 

2. There is a heightened irritability in all inflammatory 
and hyperemic diseases of the external, middle, and inter- 
nal ear, and in the initial stages of a central cerebral disease. 

3. The mode of reaction of the auditory nerve to the elec- 
tric current is analogous to that observed in the other sen- 
sory and motor nerves. 

In regard to the first proposition, it may be remarked 
that even the earliest followers of Brenner's doctrines be- 
came more and more reluctant to designate the acoustic 

^ " Petersb. raed. Zeitschr.," 1891 ; reported in "Arch. f. Ohr.," VI, p. 147. 
2"Wien. klin. Wochen.," 1888, Nos. 31, 32. 
8 " Arch. f. Ohr.," XXVII and xxviii. 



268 NERVOUS DISEASES. 

reaction as the normal formula to be aimed at in the healthy- 
individual. Schvvartze was not able to obtain the reaction 
in every case ; later, Gradenigo found it present in only 
from 5^ to 12^ of normal ears, and then only when a 
higher current strength was employed, usually from 10 to 
16 m.a., certainly never under 6 m.a. This agrees with 
Erb's 1 more recent publication, in which he says that gal- 
vanic stimulation of the auditory nerve is not always pos- 
sible. As a very strong current is requisite to obtain the 
reaction in healthy individuals, the examination is usually 
attended with very unpleasant concomitant phenomena, 
such as vertigo and flashes of light. 

It is therefore better to assume that there is a pathologic 
condition of the nerve whenever there is hyperesthesia to the 
galvanic current and not to attempt to lay down any normal 
reaction for healthy individuals. Daily experience shows 
that electric excitability is not common in persons the sub- 
jects of ear disease. Gradenigo found that he could usually 
obtain the reaction in 66^ of cases of ear disease with a 
current strength of from i to 3 m.a., and always with a 
strength of less than 6 m.a. Although this increased ex- 
citability of the auditory nerve to weak currents undoubtedly 
points to pathologic processes in the organ of hearing, it 
has no special diagnostic significance, as it may occur in a 
great variety of diseases both of the ear and of the nervous 
system. It is much to be desired that ear specialists might 
contribute more to the investigation of electric excitability 
of the auditory nerve, in the hope of obtaining some definite 
diagnostic points ; for the prevailing theory that the audit- 
ory nerve reacts readily in those diseases of the middle or 
the internal ear that are accompanied by intense inflamma- 
tory processes, but fails to react after the inflammation has 
subsided, and that the reaction of the nerve in acute or 
chronic exudative or nonexudative catarrh of the middle 
ear and in cases of gradual extension of such disease to the 
internal ear does not differ from that w^hich occurs under 
normal conditions (Gradenigo), ^ is in urgent need of further 
elucidation, as it is in direct contradiction to other observa- 
tions, especially those published by Erb,^ which are in every 
way admirable. 

1 Ziemssen's " Handb. der allgem. Ther.," ni, 18S2, p. 236. 

2 "Arch. f. Ohr.," xxviii, p. 247. 

3 Ziemssen's " Handb. der allgem. Ther.," ui, 1882. 



ELECTRIC REACTION. 269 

The power of hearing does not appear to bear any rela- 
tion to the electric behavior of the auditory nerve. Accord- 
ing to Gradenigo, the greatest value of galvanic hyperes- 
thesia of the auditory nerve in diagnosis of central abscess 
of the nervous system is found in connection with brain- 
tumor ; he found the phenomenon present in all but one 
out of 18 cases. In tabes dorsalis, multiple sclerosis, and 
chronic myelitis it is absent, according to Gradenigo, but is 
said to have been observed by Erb. Gradenigo points out 
that in subnormal sensitiveness to auditory impressions in 
hysteria the electric reaction of the auditory nerve is never 
increased. ^ 

It is worthy of remark that ocular disturbances due to 
central or intracranial paralytic lesions in the domain of the 
organ of sight, such as ocular palsies and disturbances of 
the accommodation, are associated with galvanic hyperes- 
thesia of the auditory nerve (Brenner, Erb). In ordinary 
disturbances associated with facial paralysis the electric con- 
ditions vary. In some cases there is hyperesthesia with 
paradoxic reaction (Remak) ; ^ a hyperesthesia was observed 
occasionally in cases of aural hallucinations (Jolly). ^ 

Finally, it may be mentioned that certain alterations occur 
in the reactions of the auditory nerve which have been de- 
scribed as a paradoxic reaction and as a galvanic hyperes- 
thesia, with anomaly and inversion of the normal formula. 
Paradoxic reaction consists in the production of sensations, 
corresponding to the indifferent electrode, in the ear which 
is not included in the circuit ; this is regarded by Erb as the 
expression of so intense a heightening of the galvanic irrit- 
ability of the auditory nerve that even the weaker loops of 
the current, which reach the ear not included in the circuit, 
are capable of producing the auditory sensation. In a case 
of complete left-sided deafness, with the remains of an old 
suppuration, Erb found the normal formula inverted, as 
follows : 

Ka. Cl 

Ka. D 

Ka. O p>' (piping sound, gradually disappearing). 

An. Cl R^ 

An. D Pec . 

An. O. 

1 " Haug's Vort.," p. 411. 

2 " Grundriss der Elektrodiagnostik u. Elektrotherapie," 1895. 

3 " Arch. f. Psych.," 1894, iv. 



2/0 NERVOUS DISEASES. 

I have seen in sclerosis of the middle ear with involve- 
ment of the internal ear cases in which the ear under 
examination presented the normal formula, while the ear 
not included in the circuit presented the paradoxic formula : 



Right. 




Left (included in circuit) 




. . . Ka. CI 


. . . R (ringing). 




. . . Ka. D 


. . . Rco. 


R 


. . . Ka. 




R 


... An. CI. ... 




Rco . . . 


. . . An. D 






. . . An. O 


. . . . R. 



As an instance of other anomalies, Erb gives the follow- 
ing reactions, which occurred in a man fifty-four years old 
with chronic impairment of the hearing, tinnitus aurium, 
and opacity and contraction of the ear-drum. 

Ka. Ci P^ 

Ka. D P 00 . 

Ka. O b (buzzing noise). 

An. CI B^ 

An. D , B >. 

An. O p >. 

It is impossible to determine whether torpor of the audit- 
ory nerve is present or not, as the reaction in the healthy 
individual is not constant. 



THE LOCALIZATION OF THE EAR IN THE CENTRAL 
NERVOUS ORGANS. 

The origin and root-fibers of the cochlear and vestibular 
nerves, which together make up the auditory nerve, are 
twofold. While our knowledge of the former is fairly 
complete, thanks to the investigations of Held, Flechsig, 
and Bechterew, any description of the latter must be largely 
hypothetic. The fibers of the cochlear nerve, the per- 
ipheral endings of which are found in the cochlea, spring 
from the ventral auditory nucleus, and to a slight extent 
from the tuberculum acusticum.^ A second system of 
fibers originates in the ventral auditory nucleus (accessory 
nucleus), and, after passing through the corpus trapezoides, 
extends to the superior olive of the same and of the oppo- 
site side. The lateral root represents the continuation of 
the cochlear tract to the posterior corpora quadrigemina. 
It is joined, however, by the fibers from the auditory 

^ After Edinger's description, p. 359, Fifth Edit. 



LOCALIZATION, 2/1 

tubercle, which run directly through the striae acustica to 
the lateral root. ^ The lateral loop ends in the posterior 
quadrigemina. Each of the posterior corpora quadrige- 
mina sends out fibers through the inferior brachia, both of 
the same and of the opposite side, to the internal genicu- 
late body, where some of these fibers end. The remainder 
pass under the pulvinar into the internal capsule, where 
they divide into two bundles and are distributed to the 
transverse convolutions of the temporal lobe (superior 
temporal convolution). " One of these bundles ascends 
in the neighborhood of the external capsule and reaches 
the auditory sphere, while the other accompanies the optic 
radiation for some distance and, after passing around the 
inferior posterior portion of the fossa Sylvii, ascends to the 
transverse convolutions in the temporal lobe close to the 
second and third convolutions." ^ 

The course of the vestibular nerve is very obscure. It 
appears to originate in the dorsal auditory nucleus or 
Deiter's nucleus, which lies to the mesial side of the resti- 
form body. Its connections with the vermiform process of 
the cerebellum are not known. 

From this description it follows that auditory disturb- 
ances may be expected in disease of the auditory nucleus 
in the medulla oblongata, of the superior olivary nucleus 
in the pons, of the posterior quadrigemina, and, finally, of 
the first (superior) temporal convolution, and in disturb- 
ances of the nervous paths which connect these nuclei. 
Tumors and abscesses, foci of softening in the brain-sub- 
stance, tubercular and syphilitic disease, cerebral hemor- 
rhage, and many other diseases of the central nervous 
system may produce a focal lesion by destroying the cen- 
tral pathways. The only symptom of such a lesion in the 
cochlear tract is difficult hearing, while vertigo and the 
signs of Meniere's symptom-complex generally are absent. 
Impaired hearing from a central cause is recognized by the 
presence of other phenomena of cerebral disease, and its 
gradual increase in a subject whose hearing had always 
been perfectly good corresponds to the gradual growth of 
the tumor. Unfortunately, we have no accurate knowl- 
edge concerning the nature of a central deafness localized 
in the cortex, but when the cause is found in a lesion of 

1 See illustration No. 247, Edinger. 

> Flechsig, " Gehirn u. Seele," 1896, p. 75. 



2/2 NERVOUS DISEASES. 

the tegmentum or mesencephalon, the resulting auditory 
disturbance presents certain characteristics, which have been 
described by Siebenmann. Bone conduction is very much 
impaired or entirely abolished. Weber's experiment is 
not regularly successful, and may be lateralized either to 
the healthy or to the affected side. In the beginning of 
the developing deafness perception is lost for the lower 
notes only, while later in the course of the disease all the 
notes of the scale become uniformly inaudible, so that 
finally the patient retains only the power of hearing a cer- 
tain number of notes in the lower middle register, as in 
diseases of the labyrinth and of the auditory nerve. 

Subjective ear noises are rarely observed. Hyperes- 
thesia of the auditory nerve appears to be possible in the 
early stages of a lesion of the auditory centers; at least, 
this would seem to explain the increased electric irritability 
of the auditory nerve described by Gradenigo. 

Oppenheim ^ quotes the statement that in tumor of the 
superior temporal convolution the epileptic attacks were 
preceded by an auditory aura. The important question 
as to which side is affected in unilateral lesion of the 
cerebral roots of the cochlear nerve has not yet been 
decided. The pathways cross each other at various 
points in their course through the pons, in the tegmentum, 
and in the corpora quadrigemina, but the decussation 
appears to be only partial, so that the cortical centers for 
hearing on both sides of the brain appear to be connected 
with both auditory nerves. The result of this arrangement 
is that unilateral disease in the region of the temporal lobe, 
where the cortical center for hearing is found, does not 
produce unilateral deafness of the opposite side (crossed 
deafness), as some authors have claimed. Permanent cen- 
tral deafness can be produced only by the destruction of 
the cortical centers for hearing in both hemispheres. 

The significance of the posterior corpora quadrigemina in 
auditory disturbances has lately been carefully investigated 
by Weinland and Siebenmann. Weinland maintains that 
disease of one of the posterior corpora quadrigemina pro- 
duces auditory disturbance on the opposite side ; while 
Siebenmann, on the contrary, claims that a lesion of only 
one of the posterior corpora quadrigemina does not produce 

^ " Lehrb. der Nervenkrankh.," p. 94. 



LOCALIZATION. 2/3 

deafness — a statement which is in direct opposition to the 
generally accepted opinion that the corpora quadrigemina 
contain one of the auditory centers. By a careful review of 
the literature Siebenmann ^ shows that in all cases of deaf- 
ness due to injury of the mesencephalon there is either 
compression or destruction of the tegmentum (or of the in- 
ternal capsule), whereas in simple cases of tumor of the 
corpora quadrigemina the hearing remains intact. From 
this he argues that the auditory disturbance is not directly 
due to the situation of the tumor in the posterior corpora 
quadrigemina, but rather to its interference with the sur- 
rounding parts and to the compression of the adjacent por- 
tions of the mesencephalon, which contain the auditory 
pathways. 

As we have just remarked, Weinland says that the loss 
of hearing occurs on the side opposite to that of the dis- 
eased corpora quadrigemina ; Oppenheim believes that 
either the ear on the same side as the tumor or that on the 
opposite side, or even both ears, may be affected ; while, 
according to Siebenmann, any lesion of the tegmentum 
produces bilateral deafness. 

The auditory disturbances that have been observed in 
diseases of the cerebellum must be attributed to extension 
of the diseased focus to the medulla oblongata and pons, or 
directly to the trunk of the auditory nerve. Such a disease 
necessarily interferes with the roots and centers of the ves- 
tibular nerve contained in the cerebellum, but as we have 
no definite knowledge of the relation existing between this 
cerebellar ataxia and the static functions of the organ of 
hearing, the question will not be included in the present 
discussion. 

It is often very difficult to distinguish an auditory dis- 
turbance due to central lesion from intracranial lesion of 
the trunk of the auditory nerve. A great number of cases 
are known in which the auditory nerve was included in 
tumors originating at the base of the brain, in the cere- 
bellum, or in the pineal body. Such tumors even penetrate 
through the porus acusticus internus into the labyrinth. 
A differential diagnosis in such cases is impossible. 

In the etiology of the auditory disturbances which we 
have just described we have so far considered only those 

1 " Zeitschr. f. Obr.," vol. xxix. 



2/4 NERVOUS DISEASES. 

diseases which produce a direct lesion of the auditory path- 
way and its cerebral centers. In other words, we regarded 
the auditory disturbance as a direct result of such a lesion. 
We must now mention another pathologic condition, which 
is recognized by various authors, and to which Gradenigo, 
in Schwartze's " Handbuch der Ohrenheilkunde," ^ assigns 
a very important place, although its occurrence is now 
generally discredited : namely, the question of the hiflitence 
oil licaring of a rise in the intracrajiial pressure. 

Reasoning by analogy from papillary congestion, it was 
natural to assume that increased intracranial pressure might 
exert some influence on the auditory nerve, as the condi- 
tions are in certain respects similar. Moos considered it 
doubtful that auditory disturbances could be due to increased 
pressure from cerebral tumors ; Steinbriigge interpreted a 
depression of Reissner's membrane as dependent on increased 
intracranial pressure (an explanation which caused some 
discussion in the Naturf. Vers, in Heidelberg, the sense of 
the meeting being that the depression was simply an arti- 
fact) ; and Gradenigo assumes that " in cases of brain-tumor 
with increased intracranial pressure, a lymphatic infiltration 
occurs at the peripheral ending of the auditory nerve anal- 
ogous to the papillary congestion of the optic nerve." 
This interpretation is very artificial and anything but unas- 
sailable, for most pathologists deny that papillary conges- 
tion of the eye is due to intracranial pressure alone, attrib- 
uting it rather to toxic influences. Although histologists 
possess perfect methods and abundant material for the 
anatomic investigation of the eye, their results are not by 
any means uniform ; how, then, can we expect to draw any 
reliable conclusion from the superficial descriptions of only 
two histologic examinations of the labyrinth, in the exami- 
nation of which it has so far been impossible to exclude 
with certainty the fallacies of artifacts? It is therefore not 
to the credit of otology, and does not in the least add to 
our understanding of the question, to erect a hypothetic 
"papillary congestion of the auditory nerve" merely for 
the purpose of substantiating a preconceived opinion. In 
addition we may mention the conclusion reached by Asher ^ 
in a very careful work on the subject — that rise in the 
intracranial pressure does not produce any constant dis- 

1 Vol. II, p. 530. 

2 "D. Zeitschr. f. klin. INIed.," 27, p. 513. 











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TABES DORSALIS. 2/5 

turbances in the organ of hearing, as the pressure conditions 
in the endolymphatic and perilymphatic spaces, which 
depend on the hydrostatic pressure of the lymphatic fluid, 
tend to regulate each other mutually, and thus to prevent 
the occurrence of excessive pressure. 



3. NERVOUS DISEASES WHICH PRODUCE DEFI- 
NITE ALTERATIONS IN THE NOSE, PHAR- 
YNX, AND LARYNX, AND IN THE EARS, 

DISEASES OF THE SPINAL CORD. 

Tabes Dorsalis. 

The occurrence of laryngeal disturbances in tabes was 
formerly regarded as very rare, and until very recently 
opinions diverged as to the existence of any relation 
between tabes and difficult hearing. But now we have a 
long series of statistics and reported cases which prove that 
the vagus and auditory nerve are comparatively often in- 
volved in tabes dorsalis, if not quite as frequently as the 
optic nerve. According to Klippel,^ the olfactory nerve 
also becomes involved in tabes, and there result disturb- 
ances of the sense of smell, manifesting themselves in uni- 
lateral anosmia, parosmia, and hallucinations of scent. 

Statistics differ very widely as to the frequency of laryn- 
geal symptoms in tabes dorsalis ; Krause found motor dis- 
turbances in 13 out of 38 cases, but does not give any 
detailed description of their nature ; Marina, on the strength 
of Fano's investigation, gives 19 cases of motor disturbances 
in 36 patients suffering from tabes, in all of which the con- 
ditions were found to be abnormal. Dreyfus found two cases 
of double posticus paralysis among 22 tabes patients ; 
Burger ^ in 6 out of 20 cases found that motor disturbance 
could be demonstrated with the laryngoscope. I may add 
that among 27 tabetic patients in the Medicinische Uni- 
versitats-Poliklinikin Leipzig I found no disturbances in the 
larynx ; while, on the other hand, in the case of one tabetic 
patient who had sought medical advice on account of dysp- 
nea I found a double posticus paralysis associated with 
paresis of the vocal cords. Statistics based on such small 

1 " Arch, de Nenrol.," 1897 ; see " .Schm. Jahrb. ," vol. CCLVii, p. 82. 

2 " Die laryngealen Storungen bei Tabes dorsalis," Leiden, 1891. 



2/6 NERVOUS DISEASES. 

material are, however, of very little value, as were shown by 
Semon, who found among the 12 first cases of tabes which 
he examined unilateral or bilateral posticus paralysis five 
times, whereas the next 30 cases did not yield a single 
laryngeal disturbance. Of more recent contributions we 
may mention that of Gerhardt,^ who found 17 paralyses 
in 122 tabetic patients, 11 of the posticus (5 bilateral, 
4 the right posticus, 2 the left posticus), and 3 of the 
recurrent laryngeal nerve (i bilateral, 2 unilateral on the 
right side). The 3 remaining cases consisted of paral- 
ysis of the posticus and thyroid muscles once, paralysis of 
the recurrent nerve of one side and of the posticus nerve of 
the other side once, and 2 paralyses of the thyroid aryte- 
noid muscle. In 2 cases there were ataxic movements of 
the vocal cords ; in 4 cases there were laryngeal crises. ^ 

Among 100 cases of tabes Semon found 8 unilateral 
posticus paralyses, 3 bilateral posticus paralyses, and 3 
unilateral paralyses of the recurrent nerve. 

The most frequent laryngeal complications consist in 
motor palsies of the laryngeal muscles. The typical tabetic 
palsy is that of the crico-arytenoideus posticus, either of one 
or of both sides. In Berger's table of 71 cases of tabetic 
laryngeal paralysis published up to 1891, there are 33 cases 
of unilateral paralysis of the posticus, in a few of which 
there was a coexistent paralysis of the intemus ; the 
remaining 38 cases consisted of unilateral paralysis of the 
posticus, while a few cases showed paralysis of the posticus 
on one side and paralysis of the recurrent nerve on the 
other. 

From this it would appear that bilateral paralysis of the 
posticus is almost as frequent as the unilateral form. It 
must, however, be remembered that the symptoms due to 
the various forms of paralysis may either be so marked as 
to produce a very noticeable alteration in the voice or res- 
piration, and thus arouse a suspicion of laryngeal disturb- 
ance, or they may be so mild as to escape the examiner's 
notice altogether, unless every tabetic patient is systematic- 
ally subjected to a laryngoscopic examination. Hence, 
unilateral paralysis of the posticus, which does not affect 
phonation and respiration, is frequenth- overlooked, while 
bilateral paralysis of the abductors of the glottis never 

1 Nothnagel's " Spec. Path. u. Ther.," vol. xiii, p. 55. 

2 " Heymann's Handb.," vol. i, p. 705. 



TABES DORSALIS. 2'J'J 

escapes detection, because it is always associated with 
hoarseness and dyspnea. 

Complete paralysis of the recurrent nerve is extremely 
rare in tabes dorsalis. As we have previously stated, a 
subacute disease affecting the nuclei of the vagus and of 
the recurrent nerve first produces paralysis of the posticus, 
which only becomes converted into paralysis of the recur- 
rent later in the disease. The question naturally suggests 
itself. Why do we not observe this transition from the 
median to the cadaveric position in those cases of tabes 
dorsalis which persist for many years, and which, as 
we know from the reports of autopsies, attack the nuclei in 
the medulla oblongata ? The only clinical fact which 
points to a progressive nature of posticus paralysis is the 
occurrence of paresis of the internus, which manifests itself 
in the laryngeal image in relaxation of the vocal cord, 
and clinically in the hoarseness and a diminution of the 
dyspnea due to the bilateral paralysis ; the rare cases 
of recurrent paralysis in tabes, being imperfectly described, 
are open to question, and can not be regarded as secondary 
to posticus paralysis. One thing is absolutely certain — the 
adductors or closers of the glottis are never affected 
alone in tabes dorsalis. The cricothyroid muscles are also 
practically never attacked ; Gerhardt's case of paralysis of 
the cricothyroid associated with that of the posticus is the 
only one that we have met with. ^ 

The laryngeal palsies are usually observed in the earlier 
stages of tabes dorsalis and sometimes precede all other 
symptoms. 

It has been occasionally stated that intermittent paral- 
ysis of the vocal cords may be observed in tabetic patients, 
and that a posticus paralysis may disappear after a few days 
and return after the lapse of weeks ; but the statement has 
not been satisfactorily proven, and until we have more 
accurate observations we must assume that once the tabetic 
paralysis has developed in the larynx there is no hope of 
cure. The paralysis may, however, develop very gradually, 
and several cases have been reported which remained con- 
stantly under observation and in which a complete posticus 
paralysis developed in the course of weeks or months : at 
first there was some power of abducting the vocal cords ; 

1 " Ann. des mal. de I'oreille," iSgi, p. 4S0. 



278 NERVOUS DISEASES. 

this gradually diminished, and finally the vocal cords 
remained immovable in the median position. 

The subjective symptoms are the same as those which 
occur in paralysis of the vocal cords from other causes. 
When there is hoarseness, a posticus paralysis produces no 
symptoms unless the vocal cords are implicated ; any marked 
disturbances always tend to posticus paralysis. The symp- 
toms consist in dyspnea, the voice being only slightly, 
if at all, affected. As the paralysis develops very gradually, 
the patient becomes accustomed to the stenotic condition of 
the rima glottidis, and the interference with respiration is 
comparatively slight, except during bodily exertion and 
phonation ; during sleep, however, the stenosis becomes 
very marked. There is a good deal of inspiratory dyspnea, 
showing itself in loud, sighing inspirations, while the 
expiration is quite free. There is, of course, a constant 
danger of asphyxia whenever a greater demand is made on 
the respiration during any form of bodily activity, so that 
sooner or later tracheotomy becomes necessary in cases of 
posticus paralysis. 

An experiment performed by Ruault deserves mention 
in this place. He excised 1.5 cm. from the recurrent nerve 
in a tabetic patient who was suffering from intense dyspnea 
due to posticus paralysis, in the hope of bringing the vocal 
cords into the cadaveric position, but the operation was not 
followed by any change either in the laryngeal image or in 
the subjective symptoms of the patient. This is the only 
case of its kind, and has no particular value. 

Ataxia of the vocal cords is a name given to a condition 
in which the vocal cords execute irregular movements dur- 
ing phonation and deep respiration. Krause was the first 
to remark that the vocal cords tended to move in jerks and 
to stop midway between complete adduction and the inspi- 
ratory position, producing interrupted or scanning speech. 
It has been elaborately proved by Burger that this motor 
anomaly, which occurs exclusively in tabes, is a true ataxia, 
or disturbance in the coordination of all the antagonistic 
groups of muscles the cooperation of which is necessary to 
produce all the movements of the vocal cords. 

Laryngeal crises consist in convulsive attacks of cough 
and dyspnea, and occur in the beginning of, or during the 
course of tabes, like gastric crises. They differ from attacks 
of simple laryngeal spasm in that all the other respiratory 



TABES DORSALIS. 2/9 

muscles are involved. The attacks either occur without 
any ascertainable cause or after slight external, mechanical, 
or psychic irritation, particularly swallowing and the intro- 
duction of a probe into the throat. According to Oppen- 
heim, pressure on the throat at a point near the anterior 
border of the sternomastoid muscle at the level of the cri- 
coid cartilage produced attacks of coughing. The attacks 
occur with variable frequency ; they may be repeated 
several times within a few hours, or a single attack may be 
followed by a period of freedom lasting for months or years, 
or may never be repeated. They are usually preceded by 
a feeling of tickling or burning in the throat ; this is followed 
by a choking attack, with loud, strident inspirations and 
short, puffing expirations, accompanied by a violent, bark- 
ing cough which has been compared to whooping-cough. 
The patient becomes intensely excited and greatly terrified 
at the idea of impending suffocation, until, after a short 
time — the attacks rarely last longer than a minute — the 
respiration is suddenly or gradually restored, sometimes 
after the expectoration of a little mucus (Burger). They 
usually end in recovery in spite of their intensity, although 
Burger was able to collect five cases which terminated 
fatally during the attack. 

Pharyngeal crises are described by Oppenheim as attacks 
of convulsive gulping movements, which, however, are for- 
eign to our subject. Sensory disturbances of the larynx 
during tabes are rare. A few cases of anesthesia and 
hyperesthesia of the pharyngeal and laryngeal mucous 
membrane have been observed. With regard to the appear- 
ances produced by tabes dorsalis in the organ of hearing, I 
shall here reprint a paper which I read before the Deutsche 
Otologische Gesellschaft in Dresden, in 1897, and which 
appeared in a rather inaccessible portion of the reports of 
that meeting : 

In spite of the fact that several papers have appeared 
on the subject of aural disturbances in tabes dorsalis, 
opinions are still divided as to their nature, and there are 
those who deny the occurrence of deafness as a result of 
tabes. 

I shall omit the list of reported cases and shall not 
repeat the various opinions which have been expressed on 
this subject, contenting myself with referring to Burger, 



280 NERVOUS DISEASES. 

Treitel,! and Haug,^ who have given a complete bibli- 
ography of the subject. I shall make it my task to attempt 
to explain the probable nature of ear disease in tabes dor- 
salis by means of our anatomic and clinical knowledge of 
the conditions. Although there are no anatomic investiga- 
tions at my disposal, I shall utilize the results of examina- 
tions made on the ears of 27 tabetic patients by a ' Doctor- 
and ' in the Medicinischen Universitats-Poliklinik at Leip- 
zig. Among these patients there were two cases of im- 
paired hearing which could with certainty be referred to 
tabes — at least, with as much certainty as the present state 
of aural examination will permit. I give the percentage as 
7.3, although I am reluctant to compute a rate on such a 
limited number of cases. At least, these investigations 
show that tabetic ear disease is extremely rare, and tally 
almost perfectly with the statistics published by Voigt and 
Treitel, who found auditory disturbances in 2 cases out 
of 100, and in 2 cases out of 20, or 2^ and 10 fo, respec- 
tively. I was unable to obtain the statistics by Marie and 
Walton in the original, but I have nothing to criticize in 
the finding of Meniere's symptom -complex in 17 out of 24 
cases ; on the other hand, I object strongly to Morpurgo's 
statement that he found in 43 cases out of 53 auditory dis- 
turbances which could be traced to tabes dorsalis — a per- 
centage of 81.13. As the diagnosis was based purely on 
a positive Rinne test, at reduced hearing-distance, and on a 
normal condition of the ear-drum, while the air douche was 
not followed by improvement in the hearing, these statistics 
are manifestly defective, and after examining the cases I 
claim that the list does not contain a single case of authen- 
tic tabetic deafness. 

The infrequency of auditory disturbances in tabes is 
confirmed by the observation of clinicians with a large 
amount of material at their command. If we compare the 
meager reports of deafness with the great number of case 
histories of tabes dorsalis contained in the literature (we 
need only mention Erb's statistics of more than 700 cases), 
our faith in an author who gives a percentage of 81.13 's 
very much shaken. 

The clinical picture of the ear affection is variously de- 

1 "Zeitschr. f. Ohr.," xx. 

2 " Die Krankheiten des Ohres in ihren Beziehungen zu den Allgemeiner- 
krankungen." Vienna and Leipzig, 1893. 



TABES DORSALIS. 28 1 

scribed. According to some, the disease presents the 
characteristics of a lesion in the sound-perceiving apparatus, 
and is distinguished by otitis interna and by the fact that 
perception for the higher notes is relatively good, while the 
hearing is impaired for the deeper and middle notes of the 
register. Others distinguish two clinical forms, one of which 
must be regarded as a simple tabetic atrophy of the audit- 
ory nerve, the other as syphilitic disease of the labyrinth. 
The former is gradual in its onset and goes on slowly to 
complete deafness, being accompanied with tinnitus aurium, 
but never with vertigo ; the latter makes its appearance 
suddenly, like a stroke of apoplexy, wdth the phenomena 
of Meniere's symptom-complex, and in many cases rapidly 
leads to total deafness. 

It follows from this divergence in the conception of 
the clinical course of the auditory disturbance in tabes that 
the most various attempts were made to explain the nature 
of the disease. Some incline to regard the process as an 
atrophy of the auditory nerve, others attribute the disease 
to trophic disturbances in the middle ear due to tabetic dis- 
ease of the trifacial nerve, while a third faction describes 
the disease as syphilitic. As I shall presently show, all 
these theories lack the support of anatomic or clinical find- 
ings, which alone afford a reliable basis for the description 
of the disease. 

Most authors interpret tabetic disease of the ears as an 
atrophy of the auditory nerve with the symptoms of a lesion 
of the sound-perceiving apparatus. It is a proof of our 
present inability to make a clinical diagnosis of atrophy of 
the auditory nerve that attempts are constantly being made 
to discover some minute changes which should be charac- 
teristic of tabetic disease of the auditory nerve. 

Gradenigo considers it characteristic of tabes when the 
perception of high notes is relatively good and the loss of 
hearing applies chiefly to the lower and middle notes ; but 
this phenomenon is not constant, to say the least, for in 
Habermann's case perception of the lower notes remained 
good after the patient was unable to hear higher ones. 
Again, many authors have emphasized the great electric 
irritability of the auditory nerve, but this phenomenon has 
not met with universal recognition, and is, moreover, of 
little value, in view of our imperfect knowledge of the 
physiology of the electric reaction of the auditory nerve. 



^82 NERVOUS DISEASES. 

The conception of a progressive atrophy of the auditory- 
nerve fails to find pathologic support, because those cases 
•in which disease of the nerve-endings in the labyrinth and 
in the nuclei was found associated with atrophy of the 
auditory nerve can not be regarded as cases of primary 
atrophy of the auditory nerve. 

Although on theoretic grounds there may be no objec- 
tion to this interpretation, since disease of the trunks of the 
-cranial nerves is said to occur in tabes, there is, as I have 
said, a complete absence of anatomic or clinical proof of its 
representing the type of a tabetic auditory disturbance ; 
consequently, other explanations were sought. When 
Lucae was able to refer the impairment of hearing in two 
tabetic patients to simple disease of the middle ear, furnish- 
ing anatomic proof in one case, it gave rise to the opinion 
that the middle-ear affection was due to tabetic disease of 
the trifacial nerve, in support of which was cited the fact, 
determined by the experiments of Baratoux, Gelle, and 
Berthold, that trophic disturbances may appear in the 
middle ear after the destruction of the roots of the trifacial 
nerve. But there is no proof whatever that such an effect 
on the middle ear through the trifacial nerve takes place in 
tabes, for in Lucae's case there were no other disturbances, 
such as would necessarily be present in any disease of the 
trunk or nucleus of the trifacial, nor was there any anatomic 
proof of such disease. On the other hand, this explanation 
is untenable from the fact that Oppenheim ^ found the 
hearing to be quite normal in a case of marked alteration 
of the trifacial where the diagnosis rested on an anatomic 
iDasis ; nor is there any mention of auditory disturbances in 
another similar case of Oppenheim's. If the opinion that 
the fifth nerve plays an important part in tabetic deafness 
were correct, the symptom would certainly have been 
present in these two cases ; its absence, however, makes 
the hypothesis very improbable. 

The syphilitic form of aural disease remains to be dis- 
cussed. This is particularly insisted upon by Haug,^ who 
appears to believe that these cases possess very character- 
istic clinical features, consisting principally of Meniere's 
symptoms, with abrupt onset, marked vertigo, vomiting, 
■and sudden deafness, sometimes associated with violent 

^ "Arch, fiir Psychistrie und Nervenheilk.," xx, p. 147. 
2 Loc. cit. 



TABES DORSALIS. 283 

pains. The objective signs, he says, differ from those in a 
simple case of tabes by the fact that bone conduction is 
completely abohshed. I can not see how these symptoms 
justify Haug in believing "that he has in all probability to 
deal with syphilis," since other nervous affections of the 
ear are accompanied by the same symptoms. Haug also 
cites the report of an autopsy which he says confirms his 
opinion, but it is left to the reader to pick out what he con- 
siders characteristic of syphilis. It appears that Haug's 
diagnosis was determined by a little round-celled infiltration 
which was found surrounding some of the smaller vessels, 
and the proliferation in the intima of the same. Haug is 
welcome to consider the ear affection in his case as syph- 
ilitic ; but, if so, it is not tabetic, and has developed inde- 
pendently of tabes. The explanation that " a primary 
syphilitic infection may give rise to the combination of lues 
and tabes which occasionally appears in the organ of hear- 
ing in the form of a labyrinth affection" seems rather 
obscure, and even if we admit a connection between tabes 
and syphilis, it is, in my opinion, a mistake to look for ter- 
tiary syphilitic changes, as such are never found in the 
parasyphilitic affections, to which the tabetic deafness in 
this case would belong. 

The latest investigations hardly admit of any other 
explanation of tabes than that it is a disease of the neurons, 
consisting principally in a lesion of the systems that take 
their origin in the spinal ganglia. I would apply the same 
explanation to the auditory disturbances which occur in 
tabes, and shall, therefore, continue the discussion of this 
question by referring to the reports of autopsies and clinical 
observations which have hitherto been published. 

For the morbid anatomy, I begin by citing a case of 
Habermann's.i in which the disease was limited to the trunk 
of the auditory nerve and its terminal endings in the laby- 
rinth, while the nuclei remained intact. It is Avorth men- 
tioning that the atrophy of the fibers of the cochlear nerve 
was not so great on the right as on the left side. . A bundle 
of nerve-fibers at the apex of the cochlea and several 
ganglion cells in the terminal portion of the basilar convolu- 
tion were preserved — a condition which manifested itself 
clinically in ability on the part of the patient to perceive 
deeper tones. 

1 "Arch. f. Ohr.," xxxiii, p. iii. 



284 NERVOUS DISEASES. 

Next, I will mention Gelle's case, which is always quoted 
in support of the doctrine of middle-ear disease in tabes. In 
a woman forty-two years of age, the subject of tabes, there 
was a sclerosis of the mucous membrane of the middle ear, 
immobility of the ear-drum and of the chain of ossicles, 
ankylosis of the stapes, and, as a result of these changes, — 
to quote the common explanation, — a slight atrophy of 
part of the various portions of the cochlea, including a dis- 
turbance of the nerve -endings on the basilar membrane. 
The nerves in the lamina spiralis, in the vestibules, and in 
the semicircular canals were not attacked. In view of the 
atrophy of the nerve-endings on the basilar membrane I 
question the propriety of regarding this case as one ot 
simple middle -ear disease, and am inclined to look upon 
it as a primary peripheral disease of the cochlear nerve. 

Striimpell has described one case of tabes in which there 
had been complete bilateral deafness for four years. Micro- 
scopic examinations revealed an evident atrophy of the au- 
ditory nerves. Nothing is said about the nuclei or the 
internal ear, although the statement that the " degenerative 
process, strange to say, disappears in the restiform body" 
justifies the assumption that if there had been any disease 
of the auditory nuclei, which are in such close proximity to 
the restiform body, it would not have escaped the author's 
notice. 

There remain to be mentioned three cases by Haug in 
two of which the cochlear and vestibular nerves appeared 
to be completely destroyed ; the trunk and nuclei of the 
auditory nerve, however, were not examined. In the third 
case the fibers of the cochlear nerve. had disappeared and 
been replaced by connective tissue, the cells of Corti's 
organs were opaque, the basilar membrane was preserved, 
while Corti's membrane and the reticular membrane were 
the seat of membranous adhesions. Unfortunately, the 
author does not give a detailed description of this very in- 
teresting aural condition, "because it would lead him too 
far afield," so that there is nothing left to discuss but the 
medulla oblongata, as the trunk of the auditory nerve was 
not examined. One of the chief nuclei showed only a 
slight degeneration of the nerve-fibers, while the other was 
quite normal. The accessory nuclei could not be made 
out, as they appeared to be replaced by round-celled infil- 
tration. There was a diminution in the number of fibers in 



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TABES DORSALIS. 285 

the ascending limb and in the mesial root of the auditory 
nerve, but none in the lateral root. 

This is the case that Haug described as syphilitic, and, 
interesting as it is in certain details, its value is very limited, 
as the anatomic examination of the medulla oblongata is so 
imperfectly described that it is impossible to obtain a clear 
mental picture. The same may be said of Oppenheim's 
case, in which it is said that nothing definite could be made 
out in the nuclei of the auditory nerve, although it was 
quite evident that a large proportion of the root-fibers, 
which leave the acoustic nucleus at the point where it dis- 
appears beneath the nucleus of the vagus and pass up over 
the ascending root of the fifth nerve, were atrophied. The 
author also says that " the root-fibers of the auditory nerve 
are deep red in color, and under a high power appear to 
have lost the characteristic appearance of nerve-fibers and 
to be converted into a wavy mass of connective tissue very 
rich in cells." The trunk of the auditory nerve and the 
internal ear were not examined. 

If we review these cases, we find an evident involvement 
of the terminations of the cochlear and vestibular nerves in 
Habermann's and in two of Haug's cases. Gelle's case 
presents atrophy of the peripheral endings of the cochlear 
nerve ; in Striimpell's case, where the internal ear was not 
examined, there was atrophy of the auditory nerve, while 
the nuclei were probably intact, and the condition in the 
labyrinth and cochlea is not known ; finally, in Haug's 
third case there was evidently deep-seated disease of the 
auditory nerve and its terminations, associated possibly 
with disease of the acoustic nuclei. It thus appears that, 
of all the parts which make up the auditory pathway, the 
terminations of the cochlear nerve and its ganglion spirale, 
the vestibular nerve, and the trunk of the auditory nerve 
are those most constantly affected, while in regard to dis- 
ease of the nuclei there are no reliable observations. This 
need not surprise us, if we consider the difficulties which 
are encountered, even in the normal condition, in the 
description of the higher auditory pathways. 

To make the matter a little clearer, I shall review once 
more the course of the auditory pathway, and for this pur- 
pose shall use the description given by Edinger. The 
cochlear nerve represents the central process of the cells of 
the ganglion spirale. P'rom this ganglion, which is situated 



286 NERVOUS DISEASES. 

in the cochlea, are derived the minute peripheral branches 
which ramify among the auditory cells. The fibers of the 
cochlear nerve, which were formerly designated as the pos- 
terior roots, enter the ventral nucleus of the auditory nerve^ 
except a small portion which go to the tuberculum acus- 
ticum. These structures together represent the primary 
neuron of the auditory pathway, the ganglion spirale repre- 
senting the ganglion cells ; the cochlear nerve, the axis- 
cylinder; and the crista acustica, the peripheral terminations. 
In the vestibular nerve the conditions are not quite so clear ; 
it appears, however, that the ganglia of the primary neuron 
are situated in the labyrinth, and from that point send out 
the peripheral terminations to the specialized epithelium in 
the ampulla, while the axis-cylinder is represented by the 
vestibular nerve which ends in the dorsal auditory nucleus. 
The course of the higher pathways, which are regarded as 
secondary and tertiary neurons, does not interest us in this 
connection ; but we may refer to the developmental rela- 
tionship probably existing between the ganglion spirale 
and the spinal ganglia, according to which it is assumed 
that the ganglion cells of the cochlear nerve in the develop- 
ment of the organism have moved out toward the periphery 
in a manner analogous to the formation of a spinal ganglion. 
This relationship appears to me to furnish the explanation 
for tabetic auditory affections, as I agree with v. Leyden 
and others in regarding tabes as a disease of the spino- 
cutaneous sensory neurons. The theory is not so far 
fetched as would appear at first sight, if we consider the 
behavior of the peripheral sensory nerves as studied by 
v. Leyden and his followers and by Oppenheim. Atrophic 
processes in the peripheral endings of the sensory nerves 
have been demonstrated in tabes, and, quite recently, Moxter 
suggested that disease of the optic nerve represents an 
affection of the neurons beginning in the peripheral endings 
in the layer of ganglion cells of the retina. As I have 
already pointed out, the most frequent anatomic alterations 
in tabetic ear disease are found in the peripheral endings of 
the auditory nerve, and I accordingly venture to express 
the opinion that the tabetic ear disease represents a morbid 
process localized in the peripheral endings in the primary 
neuron of the auditory nerve ; that is to say, in the endings 
of the cochlear nerve, the ganglion spirale and its axis- 
cylinder, and the trunk of the auditory nerve. 



TABES DORSALIS. 28/" 

This conception of the seat of the disease would seem to 
agree with the clinical picture described by Haug in a pure 
tabetic form of disease of the auditory nerve, for he described 
it as a very gradual impairment of the hearing, depending 
on atrophy, and associated with subjective noises. 

As an illustration of the clinical picture, I shall describe 
one of the two cases of tabetic ear disease which I had the 
opportunity to observe. A woman fifty years of age had 
been suffering from symptoms of tabes for a number of 
years ; the patellar reflexes were entirely abolished, the 
gait was ataxic, the pupils were almost rigid, and Rom- 
berg's phenomenon could be easily demonstrated. Within 
the last three years the hearing, which had never been 
good, gradually deteriorated. The optic nerve was intact. 
The patient complained of humming and buzzing noises in 
the ears, at times so marked as to give the impression of 
the ringing of bells, the twittering of birds, etc. On exam- 
ining the ears, an old perforation was found in the right ear- 
drum in the anterior inferior quadrant, together with 
marked calcification, while on the left side the membrane 
showed opacities. 

There had evidently existed an old purulent otitis media, 
which not improbably bore some relation to an atrophic 
rhinitis still present. 

When the functional test was applied, it was found that 
the internal as well as the middle ear was involved. Bone 
conduction was entirely abohshed. On the other hand, the 
deeper and middle notes were very faintly heard on the 
right side (C only in strong vibrations of the fork, C2 = 
— 60'' ),i and somewhat better on the left side (C := — 35, 
C = — 5") ; whereas the highest notes (C- and Galton's- 
whistle) were quite inaudible on the right side ; on the 
left, however, C. could just be heard when it was lightly 
touched, while Galton's whistle was also inaudible. On 
both sides speech could be heard only when it was very 
loud. The occurrence within the last three years of a very 
noticeable and rapidly increasing deafness justifies the 
assumption that two different processes are present, one of 
which ran its course years ago in the middle ear while, 

1 Normal period of tone-perception is as follows : 
C = 1 10^^. 

C5 = 15^^ 



288 NERVOUS DISEASES. 

the nervous deafness of the last few years bears a causal 
relationship to the tabes. 

It remains to speak of the other form of tabetic ear dis- 
ease which is characterized by abrupt onset and the pres- 
ence of Meniere's symptoms. Instead of giving a detailed 
description of its symptomatology, I shall illustrate it by 
the following history — that of my second case : The patient, 
forty-eight years old, was suddenly seized during the night 
with violent vertigo and tinnitus aurium. This was in 
1887. He described the subjective noises as " the thun- 
dering of a hundred cannons, the ringing of bells, and the 
rumbling of railroad trains." At the same time he was 
seized with violent vomiting, repeated from twenty to thirty 
times before the next morning, when the physician was 
-called and administered a remedy. Immediately after the 
attack the patient noticed that he was deaf on the right side. 
Vertigo appeared repeatedly during the next two years, 
especially after exertion. Tinnitus aurium did not occur 
again, but for several years he complained of frequent ring- 
ing of bells. This now, however, has ceased. 

The tabes seems to have appeared at the same time as 
the aural affection ; at least, the patient dates the first 
occurrence of violent tearing and dragging pains in the legs 
from that time. Three years ago a visual disturbance was 
added, consisting, on the left in a complete, and on the 
right side in a fairly well advanced, gray atrophy of the 
optic nerve (examination by Professor Schroter). Both 
ear-drums were normal. 

The result of the functional test was as follows : Bone 
conduction is very much abridged, but the tuning-fork is 
heard at the point where it is applied, except that when 
placed on the right mastoid process the sound is heard on 
the left side. Rinne on the left side, + ; the right side 
could not be tested. 

The right ear is entirely deaf for all the notes and also 
for loud speech, while in the left ear the hearing is normal, 
except that there is a slight shortening of the period of tone- 
perception for C. 

Similar histories are reported by Althaus ^ and Haug, 
and it is quite evident that in this form of tabetic ear disease 
we must look for another situation than the one we have 

1 " Arch. f. klin. Med.," xxiii, p. 601. 



MULTIPLE SCLEROSIS. 289 

been able to demonstrate for the atrophy which begins 
gradually at the periphery. I shall not attempt to attribute 
this form to syphilis, as there is not the shadow of a proof 
that it is of a syphilitic nature. But I do venture the sug- 
gestion that this form of tabetic disease of the auditory 
nerve is localized in the nuclei of the medulla — an assump- 
tion which finds some justification in Haug's third case, in 
which these nuclei were evidently the seat of pathologic 
changes, while the clinical picture during life had been such 
as we have just described. 

Since it has been found, according to v. Leyden, that 
the nuclei of most of the cranial nerves are diseased in 
tabes, either with or without a coexistent degeneration of 
the corresponding peripheral trunks, I see no reason why 
we should not assume the occurrence of a similar disease 
in the auditory nerve. Thus, without being obliged to 
resort to some other unknown factor, we have a most 
natural explanation for this form of aural disease. I should 
like to add another feature, which irresistibly forces itself 
on the observer's notice in the clinical picture of this last- 
named variety. Jt is the abrupt onset of the auditory dis- 
turbance which so strongly suggests laryngeal and gastric 
crises. As these conditions are occasionally found asso- 
ciated with atrophy of the nuclei and roots of the vagus, it 
seems permissible to assume disease of the acoustic nucleus 
as the cause of these auditory crises. Finally, the imme- 
diate occurrence of paralysis of the vocal cords after lar- 
yngeal crises also suggests the probability that an auditory 
crisis is followed by deafness. 

But this leads us into the realm of hypothesis. It must, 
however, be admitted that such apoplectic forms of deaf- 
ness not rarely occur in other diseases, so that the question 
whether they represent an intercurrent affection or a true 
complication of the primary disease is an extremely diffi- 
cult one to decide. 

Multiple Sclerosis. 

In multiple cerebrospinal sclerosis various motor dis- 
turbances occur in the larynx which are accompanied with 
intention tremors and differ from the tremulous movements 
of the vocal cords due to other causes by the fact that they 
are observed only during phonation, instead of both in 
phonation and in respiration. 
19 



290 NERVOUS DISEASES. 

The most important disturbances are : 

1. A retardation of the muscular movements, so that the 
intended movements of the vocal cords are delayed and 
accompanied with tremulous movements. 

2. Abnormal tendency to fatigue in the muscles. The 
voice is quickly fatigued by speaking, and it becomes impos- 
sible to sustain a tone for any length of time ; the speech 
is scanning and frequently interrupted by high-pitched, 
explosive sounds, due to the twitching movements of the 
vocal cords. 

3. The tension and adduction of the vocal cords are 
incomplete, so that the voice is often rough, deep, and 
hoarse. 

4. Muscular palsies. These are rare, and occur more 
frequently in the adductors than in the abductors of the 
vocal cords. 

To illustrate these phenomena I may mention Lori's ^ 
observations, in which there was a marked interval be- 
tween the muscular act of bringing the vocal cords into 
the phonatory position and the production of the tone. 
Whenever the patient was asked to imitate a sound, 
"a slight vibratory motion was immediately observed 
in the vocal cords, resembling fibrillar twitchings," but 
adduction and tone-production were delayed longer than in 
a healthy subject. Von Krzywicki ^ gives this description 
of the process : During phonation there is a slight twitch- 
ing in the neighborhood of the vocal processes in the 
direction of the median line ; this soon passes into a general 
tremor of both cords, which are finally brought together 
by an abrupt movement ; at the end of phonation the return 
to the respiratory position is accompanied by two or three 
pendulum-like vibrations toward the median Hne. 

The adductor palsies reported by Lori ^ and Krause,* 
consisting in gaping of the rima glottidis during phonation, 
are probably to be attributed exclusively to muscular weak- 
ness. Riegel's case of paralysis of the recurrent on the right 
side, with posticus paralysis on the left, is the only one of 
its kind ; it may possibly be due to paralysis of the medul- 
lary nucleus. 

1 "Die durch andervveitige Erkrankungen bedingten," etc., p. 12. 

2 " Berlin, laryng. Gesellsch." in " Semon's Centralbl.," vill, p. 506. 

3 " Deutsche med. Wochen.," 1893, p. 678. 

* Krause, " Berlin, klin. Wochen.," 1886, p. 557. 



I 



SYklNGOMYELIA. 29 1 

Our knowledge of disturbances in the organ of hearing 
in multiple sclerosis is very imperfect. Moos ^ quotes 
cases of tinnitus aurium and deafness from the literature, 
and adds one of his own, in which there was difficult hear- 
ing with loss of bone-conduction, associated with anesthesia 
of both trifacial nerves and ataxia — a condition which led 
him to seek the seat of the disease in the medulla oblongata. 
In a case reported by Hess ^ deafness suddenly developed 
in both ears two weeks after the appearance of palsies in 
the extremities ; the hearing subsequently improved on the 
left side, but was permanently aboHshed on the right. 
Microscopic examination later revealed a sclerotic focus, 
which had completely destroyed the " nucleus acusticus 
medius sinister," while on the right side only a moderate 
number of diseased ganglion cells were found. 

Moos is therefore lea to believe that the auditory dis- 
turbances in multiple sclerosis depend on sclerotic degen- 
eration of the auditory nuclei and of the trunk of the 
auditory nerve. 

We may also have auditory disturbances due to paralysis 
of the nucleus in epileptiform attacks during the course of 
a disseminated sclerosis. Oppenheim ^ observed a sudden 
onset of paralysis of the facial, auditory, and trifacial nerves 
of the same side, with symptoms of vertigo ; the paralysis 
subsided in a few weeks and was followed after several 
months by a sudden hemiataxia, which disappeared in its 
turn, 

DISEASES OF THE MEDULLA OBLONGATA. 

Syringomyelia. 

In this disease we have, either late or in the initial stages, 
the appearance of bulbar phenomena, manifesting themselves 
in motor disturbances in the larynx and in reduced reflex 
irritability of the posterior pharyngeal wall and of the lar- 
ynx ; there is no record of sensory disturbances in these 
structures having been observed. Motor disturbances of 
the uvula do not appear to occur. Schlesinger ^ collected 
12 cases of syringomyelia with laryngeal complications, 

^ " Schwartze's Handb. der Ohrenh.," I, p. 507. 
2 Dissert., 1888 ; quoted by Moos. 

* Quoted by Leyden-Goldscheider, Nothnagel's " Spec. Path. u. Ther.," 
X, 2. Th., I. Abth., p. 474. 

*"Neurolog. Centralblatt," 1894, p. 684. 



292 NERVOUS DISEASES. 

which had been pubhshed up to that time, adding five obser- 
vations of his own. Since then two other cases have been 
pubhshed by Weintraud. ^ 

From these 19 observations it appears that the palsy 
consists usually in unilateral paralysis of the vocal cord, 
due to paralysis of the recurrent or, rarely, of the posticus ; 
bilateral paralysis of the recurrent was observed in only 
four cases. 

As sometimes occurs in bulbar palsies, the paralysis of 
the vocal cords is often combined with palsy and atrophy 
of the trapezius, a fact which, as we have mentioned 
before, has been used as an argument for the spinal acces- 
sory being the motor nucleus of the larynx. Two cases 
of this kind, in which paralysis of the spinal accessory 
was combined with posticus paralysis, are reported by Wein- 
traud.^ 

Progressive Amyotrophic Bulbar Paralysis. 

Diseases of the bulbar motor vago-accessory nucleus 
lead to paralyses which may be unilateral or bilateral and 
may affect either the posticus or the recurrent nerve. They 
are found in progressive bulbar paralysis more frequently 
than in any other bulbar disease, but they can not be said 
to occur with such regularity as to justify the designation 
of the disease as " paralysie glosso-labio-laryngee." 

Anesthesia of the pharyngeal and laryngeal membrane is 
not present, as a rule, but the pharyngeal, uvular, and lar- 
yngeal reflexes are abolished. Schrotter ^ mentions the 
occurrence of paresthesia in the throat, variously described 
as a feeling of dryness or as a sense of pressure. 

According to v. Leyden,^ the auditory and Deiter's 
nuclei undergo atrophy in bulbar paralysis, forming in this 
respect an exception to the other sensory nuclei, and per- 
haps explaining the occasional impairment of hearing, going 
on to deafness, and the tinnitus aurium which is sometimes 
observed. 

The phenomena produced by progressive amyotrophic 
bulbar paralysis may also be observed in acute bulbar pal- 

1 " Deutsche Zeitschr. f. Nervenheilk.," v, 1894, p. 383. 

2 Loc. cit. 

3 " Vorles. iiber die Krankh. des Kehlkopfs," p. 382. 

*Von Leyden and Goldscheider, Nothnagel's "Spec. Path. u. Ther.," 
X, 2, pp. 686 and 701. 



PARALYSIS AGITANS, 293 

sies, such, for instance, as follow embolism or compression 
of the medulla by tumors. The latter form, which should 
be designated compression bulbar paralysis, since it is 
caused by irritation of the medulla from the pressure of the 
tumor, manifests itself in ataxic movements of the vocal 
cords. 1 Lastly, we must mention progressive spinal mus- 
cular atrophy and amyotrophic lateral sclerosis, which, by 
combining with bulbar paralysis, may produce bulbar palsies 
in the larynx. 

In pseudobulbar paralysis, which has its principal seat in 
the cerebrum, Lannois,^ Cartaz,^ and Krause^ observed ad- 
ductor palsies. The latter might be regarded as cerebral 
palsies, did we not know that there are always some diseased 
foci in the medulla and in the pons, besides the principal 
focus in the cerebrum. As it is uncertain whether vocal- 
cord paralyses ever occur in cerebral disease, one should 
never forget that they may possibly be explained by a 
simultaneous involvement of the medulla oblongata. 

NEUROSES. 

Paralysis Agitans. 

Paralysis agitans gives rise to motor disturbances in the 
vocal cords affecting the quality of voice and speech. In 
the laryngeal image we see twitching movements of the 
vocal cords, which occur regularly in phonation and usually 
also in respiration, thereby distinguishing themselves from 
similar movements observed in multiple sclerosis ; thus, Fr. 
Miiller ^ observed the phenomenon constantly when the 
patient exerted himself during the examination, but found 
that at other times the vocal cords remained perfectly quiet. 
The tremors may also affect the epiglottis (Rosenberg) and 
the uvula. 

According to Rosenberg,*^ similar disturbances of the 
speech occur as in multiple sclerosis. We have the scan- 
ning speech, described by Charcot '^ as tremulous and inter- 
rupted, like " the speech of an inexperienced rider on a 

1 Compare v. Leyden and Goldscheider, loc. cit., p. 711 ; and Semon- 
Heymann's " Handb. der Lar.," I, p. 761. 
- " Rev. de medece," 1885. 
3 " France medicale," Nov. 17, 18S5. 

* *'The Jour, of Larj'ng. and Rhinol.," 1S8S, p. 255. 

* " Charite Ann.," 1887, xn, p. 267. 

« "Berlin, klin. Wochen.," 1892, p. 771. 
' Quoted by Fr. Miiller. 



294 NERVOUS DISEASES. 

high-Stepping horse," and, as a very conspicuous feature, a 
sudden change from a high to a low register during speak- 
ing, due to the inabiHty to sustain a tone for any length of 
time ; as the vocal cords gradually relax their tension and 
closure of the glottis becomes imperfect, the voice becomes 
deeper and rougher. 

Although only a few cases ^ of laryngeal involvement in 
paralysis agitans have been reported, it does not seem to 
be a very rare occurrence, judging from Schultz's report 
of five observations of tremors in the vocal cords out of 
twelve cases in Gerhardt's clinic. As the head tremors 
themselves lead to disturbances of speech, it is very prob- 
able that they often mask the symptoms of motor dis- 
turbances in the vocal cords, and are thus the cause of 
the latter's escaping detection. 

Epilepsy. 

According to Gottstein,^ anesthesia of the laryngeal 
mucous membrane is a constant accompaniment of the epi- 
leptic attack, and may occasionally persist for some time 
afterward. The epileptic cry, which frequently heralds 
the attack, is accompanied by convulsive movements of 
the laryngeal muscles, consisting either in twitching of the 
vocal cords or in spasm of the glottis. Semon^ attributes 
these phenomena to a cortical irritation. 

It is a well-known fact that an epileptic aura often con- 
sists in disagreeable olfactory sensations. 

We also hear of auditory aurse, consisting either in im- 
paired hearing and deafness, or in the hearing of subjective 
noises, which may be so marked as to deserve the name of 
hallucinations. A few cases have been reported in which 
epileptic attacks were followed by deafness, shown by the 
functional test to be of central origin. 

In one case the deafness Avas permanent ; "* in another, 
recovery occurred "after" employment of the galvanic 
current. ^ 



1 " Charite Ann.," 18S7, p. 267. "Berlin, klin. Wocben.," i! 
771. Schultzen, " Charite Ann.," 1894, XIX. 

2 " Lehrbuch der Kehlkopfkrankheiten." 

' In Heymann's " Handb. der Laryngol.,'' vol. I, p. 632. 
* "Arcb. f. Ohr. ," xxii, p. 205. 
5 "Arcb. f. Obr.," xiv, p. 134. 



CHOREA MINOR, HYSTERIA. 295 

Chorea Minor. 

The use of the term "chorea laryngis " for disturbances 
of coordination in the movements of the vocal cords in 
various diseases is unfortunate, as it confuses the question 
whether laryngeal disturbances may occur in chorea minor. 
It seems probable that the vocal cords rarely participate in 
true choreic movements. Schrotter ^ says that temporary 
convulsive contractions occur in the larynx simultaneously 
with similar movements in the respiratory muscles, and 
represent the cause of the sighing or gasping inspirations, 
which are frequently audible at some distance. 

The disturbances of speech, which in severe cases man- 
ifest themselves as sudden interruptions by shrill whistling 
sounds, are also to be attributed to choreic movements of 
the muscles concerned in deglutition and respiration. 

According to Haug,^ the tensor veli palati and tensor 
tympani sometimes share in the contractions, and lead to 
the production of subjective or objective noises in the ear, 
described as the cracking of nuts or the crackling of 
paper. 

Hysteria. 

Hysteria is to be regarded as a neurosis without anatomic 
basis in which an alteration in the psychic condition of the 
patient is the most important factor. The clinical pic- 
ture may assume an infinite variety of forms, but all the 
symptoms have this in common — that they affect those func- 
tions of the body which are, to a certain extent, subject to 
the will of the patient. Striimpell insists that hysteria 
shows so marked a preference for the voluntary functions 
that it does not occur at all in the domain of the involuntary 
muscles and of the automatic reflexes. This law appears 
to hold good for the regions with which we are now con- 
cerned, for we shall see that hysteric phenomena, although 
they may at first sight appear to be quite irregular, never- 
theless seem to follow a certain system in the upper air- 
passages and in the ear, inasmuch as they do not affect 
those functions of the larynx and of the ear which are con- 
sidered purely automatic, such as the respiratory dilatation 
of the glottis and the static function of the ear. It is con- 

1 " Die Krankh. des Kehlkopfes," First Edit., p. 3SS. 

2 " Die Krankh. des Ohres," etc., p. 204. 



296 NERVOUS DISEASES. 

venient to divide hysteric disturbances into those which 
affect the sensory region, those which affect the motor 
region, and those which affect the regions of special sense. 

In the sensory disturbances in the region of the upper 
air-passages we have to deal with mucous membrane in the 
nose, with the exception of the vestibule ; and in the organ 
of hearing, both with epidermis (which covers the internal 
auditory meatus and the external surface of the ear-drum), 
and with mucous membrane, which forms the lining of the 
middle ear and of the tubes. 

The disturbances of special sense include alterations of 
the senses of smell and hearing ; these are usually asso- 
ciated with sensory disturbances. 

The motor disturbances embrace those which occur in 
the regions of the pharyngeal and laryngeal musculature 
and in the muscles of the tubes and of the middle ear. 

I . In the first group we have anesthesia and hyperes- 
thesia, analgesia and hyperalgesia. 

Although in general the law holds good that mucous 
membranes adjoining the external skin, as in the vestibule 
of the nose, present the same sensory disturbances as the 
adjoining external skin, this, as pointed out by Lichtwitz,^ 
is not the case when large areas of the surface are dis- 
eased. This applies particularly to hemianesthesia of 
the body-surface. We learn from the accurate studies of 
Lichtwitz, which harmonize with the results obtained by 
Thompson and Oppenheim,^ that in a purely cutaneous 
hemianesthesia the hemianesthesia of the mucous membrane 
is never complete, but usually extends over both halves of 
the body ; and, just as there may be cutaneous hemianes- 
thesia without involvement of the mucous membranes, so 
the latter may be affected while the skin remains intact. 
A characteristic feature of hysteric disturbances of sensa- 
tion, which is also observed when other portions of the 
body are attacked, is that the distribution of the anesthesia, 
instead of corresponding to the distribution of certain 
nerves, is a diffuse one, without any reference to the in- 
nervation — so much so that it furnishes an important point 
in the differential diagnosis from anesthesias due to an 
organic, anatomic lesion in which the sensory disturbances 
are strictly limited to the domain of the affected nerves. 

1 "Les anesthesies hysteriques des muqueuses," etc., Paris, 1S87. 
2'«Arch. f. Psych, u. Nervenheilk.," xv. 



HYSTERIA. 297 

The nasal mucous membrane is less apt to be included in 
the anesthesia than are the other mucous membranes of the 
upper air-passages ; the anesthesia never affects its entire 
surface, and there are always islands of intact mucous mem- 
brane between the anesthetic areas. According to Licht- 
witz, the septum always escapes, except in the lower 
anterior portion, which lies within the domain of the 
vestibule. 

The pharyngeal mucous membrane is very frequently 
affected, perhaps more frequently than any other part of 
the upper air-passages, including the larynx. The occur- 
rence of anesthesia of the epiglottis, which was regarded 
by Chairon as pathognomonic of hysteria, is not con- 
firmed by other authors. It is difficult to determine the 
frequency of anesthesia in the upper air-passages, for it 
necessarily escapes the notice of the patient and does not 
betray itself to the physician by any visible alterations ; it 
can, therefore, be detected only by a special examination. 
Sometimes we are led to suspect it by the ease with which 
a laryngoscopic examination is performed, for the absence 
of subjective complaints is often a very marked feature. The 
fact that particles of food do not find their way into the 
air-passages and lead to inspiration pneumonia, as in 
all organic palsies, especially in postdiphtheric anesthesias 
and in bulbar palsies, leads us to conclude that reflex 
swallowing and reflex cough are not affected in anesthesias 
of the pharynx and larynx. The choking reflex, on the 
other hand, is frequently abolished.' 

Diminished sensibility of the mucous membrane fre- 
quently occurs in hysteria, but it can not be separated from 
anesthesia. 

Analgesias have been observed in connection with anal- 
gesia of the .general body surface ; they may or may not be 
associated with anesthesia. 

There is another important group of hyperesthesiae and 
paresthesias, which differ from the sensory disturbances 
just described in the fact that they occasion marked sub- 
jective symptoms and may lead to demonstrable altera- 
tions in the mucous membrane in the form of hyperemias 
and consecutive chronic catarrh, as a result of the vio- 
lent efforts at swallowing and the constant coughing 
and hawking. In such cases the paresthesia is usually 
caused by the conversion of the temporary irritation in the 



298 NERVOUS DISEASES. 

larynx or pharynx — a passing inflammation or slight ca- 
tarrh — into a permanent neurosis, as a result of the hysteric 
disposition. The patients complain of a persistent tickling 
sensation, which they usually attribute to a foreign body, 
like a particle of food, on a particular spot in the throat. 
In either case a coryza or simple sore-throat is followed by 
hyperesthesia of the pharynx. Sometimes a nauseating bit 
of food or a mouthful of foul water, during bathing, for 
instance, may lead to hysteric disturbances. 

Hyperesthesia and paresthesia manifest themselves in the 
nasal mucous membrane in sneezing, and in the pharynx 
and larynx in coughing, hawking, and straining, or even in 
vomiting, or sometimes in a constant desire to swallow. 
To this category belongs the globus hystericus, which 
gives the sensation of a spherical body moving up and down 
between the region of the epigastrium and the throat. 

Under the name of anaesthesia dolorosa Schnitzler has 
described a peculiar variety of sensory disturbance in the 
pharynx, in which subjective pain in the throat is associated 
with anesthesia of the soft palate, of the posterior laryngeal 
wall, and of the larynx. 

When the diseased structures were examined, the finding 
in the nose and throat was negative, while in the pharynx 
and larynx certain alterations were seen, which were in- 
terpreted as a mild congestive or hypertrophic condition. 
The mucous membrane in the pharynx, and occasionally 
at the entrance to the larynx, may be abnormally pale, and 
in that case represents part of a general anemia, such as 
we expect to see in hysteric women. On the other hand, 
the opposite condition may be present, in which case the 
congestion of the mucous membrane must be regarded as a 
result of the irritative cough, and as an expression of the 
plethora such as we not infrequently observe in elderly 
women with excitable sexual feelings that have never been 
gratified. 

The auricle, the skin of the external auditory meatus, and 
the epidermis of the ear-drum are all subject to the sensory 
disturbances which have just been mentioned, and which 
may be either unilateral or bilateral. The anesthesia is 
not accompanied by any subjective symptoms, for Gelle's 
opinion that the ability to locate the source of the sound 
is disturbed in unilateral anesthesia of the ear-drum has not 
been confirmed. In hyperesthesia both of the external ear 



HYSTERIA. 299 

and of the Eustachian tube there are marked subjective 
symptoms in the form of paresthesia in the external audit- 
ory meatus or an aggravation of an already existing trifling 
affection of the organ of hearing. The presence of very 
small masses of cerumen on the walls of the external meatus 
often produces a distressing sense of a foreign body in 
hysteric persons, while the scratching induced by the irri- 
tation of the paresthesia may set up a mild dermatitis, 
which gives the patients great distress, so that they often 
complain of a feeling as if there were a movable foreign 
body or an insect in the ear. The hyperesthesia in the 
mucous membrane of the tubes is said to manifest itself in 
unusual sensitiveness to catheterization and to the passing 
of a bougie. Hyperesthesia and hyperalgesia of the ear 
occur, being usually localized in the middle ear (otalgia 
tympanica) or in the mastoid process. The phenomenon 
known as '' transfert,'' to which we shall refer again later, 
has been observed in the ear during these disturbances of 
sensibility. 

In this connection we must mention the so-called hyster- 
ogenic zones, irritation of which is said by Lichtwitz to bring 
on a hysteric attack, unless the parts have been previously 
cocainized. They have been located in the mucous mem- 
brane of the nose, in the larynx, on the posterior wall of 
the nasopharynx, on the posterior surface of the uvula, on 
the mucous membrane of the tubes, in the external auditory 
meatus, and on the ear-drum ; sensation was preserved in 
the parts affected. These hysterogenic zones possess no 
great practical value, and are no more significant than any 
other sensitive portions of the body, the irritation of which, 
as is well known, may produce hysteric attacks. The fact 
that a hystero-epileptic attack or any other motor reflex 
phenomenon may be induced by probing a hypertrophied 
region in the pharyngeal mucous membrane, by introducing 
a catheter into the tube, or by syringing the ear for the 
purpose of removing a plug of cerumen, is of no more sig- 
nificance than the production of similar phenomena by irri- 
tation of any given region on the external skin. Thus, 
touching a small wart on the hand has produced general 
hysteric convulsions which disappeared after the w^art was 
removed with a galvanic cautery. But this would liardly 
justify us in speaking of a hysterogenic zone, any more than 
the phenomenon of a woman being seized with hysteric 



300 NERVOUS DISEASES. 

respiratory convulsions when a catheter was introduced 
into the Eustachian tube. 

Hysteric disturbances in the nerves of special sense mani- 
fest themselv^es in the olfactory nerve as hyperosmia, hypos- 
mia, and parosmia. The effect on the function of hearing in 
hysteria shows itself either in deafness (hypassthesia acus- 
tica) or in abnormal sensitiveness of the auditory nerve 
(hyperaesthesia acustica). . These disturbances may occur 
suddenly after fright or any violent emotion, or they may 
develop gradually. It is very rarely that they constitute 
the only hysteric symptom, as other nerves of special sense, 
particularly the optic nerve, are nearly always involved. 
Natier claims to have observed a remarkable combination 
of hysteric deafness with inability to speak, or with func- 
tional disturbances of the voice, such as stammering and 
hoarseness. Diminished or increased sensibility of the 
auditory nerve are, as a rule, unilateral. In a relatively 
large number of cases the power of hearing is found to be 
abnormally increased on one side and diminished on the 
other. This condition is very conspicuous in a case 
reported by Urbantschitsch.^ in which the phenomenon 
known as '' trajtsfert" was typically present. As Haber- 
mann ^ and others have been able to perform this experi- 
ment, which is specially dwelt on by French writers on 
hysteric deafness, it may be worth while to devote a few 
words to it in this place. 

By means of a small magnet or a piece of metal (gold) 
placed on the sound ear it is possible to transfer the hys- 
teric deafness or any existing anesthesia of the ear to the 
sound side. Urbantschitsch observed that the higher notes 
are the first to be transferred, and, conversely, as the 
" transfa-t''' returns to the side originally affected, the 
hearing is lost for the higher notes sooner than for the 
lower ones. A somewhat frequent phenomenon is the 
alternation between diminished and increased sensibility at 
certain hours of the day. 

The auditory disturbance in hysteria is characterized by 
a uniform loss of perceptive power for all the notes in the 
scale. It does not exactly correspond either to a nervous 
affection or to disease of the sound-perceiving apparatus, 
for Rinne's test is usually positive, while in Weber's experi- 

1 "Arch. f. Ohr.," vol. xvi, p. 176. 
* " Prag. med. Wochen.," 18S0, No. 22. 






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* HYSTERIA. 301 

ment the tuning-fork is heard equally as often on the sound 
as on the diseased side, or may even not be lateralized to 
either side. 

Subjective noises are not constantly present. Hyper- 
aesthesia acustica manifests itself either in morbidly sensitive 
hearing or in the appearance of hysteric convulsive phe- 
nomena, when certain tones are heard. Steinbriigge ^ 
describes a very interesting case of this kind, in which the 
hearing of musical tones was followed by hysteric respira- 
tory convulsions. It is worthy of remark that disturbances 
of the hearing in hysteria are not accompanied by disturb- 
ances of the equilibrium, such as occur in organic disease 
of the auditory nerve as a part of Meniere's symptom- 
complex. 

The symptoms which we have just described make it 
appear very improbable that the seat of the lesion is in the 
auditory pathway. The phenomena of " transfert " and 
the variation in the degree of deafness appear to show that 
the perceptive faculty of the nervous auditory apparatus is 
not impaired, and that the disease is to be sought in an 
interruption of the nervous pathway which conveys the 
auditory impression to the seat of consciousness and trans- 
forms it into a sound ; hence, we probably have to deal 
with a simple disturbance of coordination in the central 
pathways, 

3. Hysteric motor disturbances are purely disturbances 
of coordination ; there is no paralysis, for the motor power 
is not lost, but there is inability to perform the muscular 
movement in such a way as to produce the desired effect. 
This disturbance between the will and the act may consist 
either in an excessive amount of muscular activity, or in a 
total want of the necessary movements, so that either the 
picture of a convulsion or that of a paralysis may be pro- 
duced. When we speak of a relation between the will and 
the deed, it is implied that the disturbance can concern only 
movements which are subject to the will and under the 
control of cortical centers of coordination, while reflex 
movements, such as are originated below the region of the 
will, like the respiratory gaping of the glottis, are not 
subject to these hysteric disturbances. 

We must, however, discuss at somewhat greater length 

1 " Zeitschr. f. Ohr.," xix, p. 32S. 



302 NERVOUS DISEASES. 

certain hysteric posticus paralyses, as Penzoldt, ^ West,^ 
and Dufour ^ have described bilateral hysteric posticus 
paralyses, and Treupel "* observed a unilateral paralysis 
which was associated with paresis of the internus. But as 
West remarks that the vocal cords were in close contact 
during inspiration and changed to the cadaveric position 
during expiration, and as Penzoldt speaks of intense 
dyspneic attacks, which imply that there were intervals of 
freedom in which the "paresis" subsided, it does not 
appear to me that these isolated cases — the rarity of which 
is in such strong contrast to the frequency of hysteric 
motor disturbances in general — furnish sufficient proof for 
a diagnosis of hysteric posticus paralysis. I rather incline 
to believe that we have to deal in these cases with a so- 
called perverse action of the vocal cords, a phenomenon 
which depends on a disturbance of coordination and con- 
sists in the approximation of the vocal cords toward the 
median line in deep inspiration, followed by separation 
during expiration, such as we very often observe in excitable 
persons at their first laryngoscopic examination. 

Motor disturbances rarely occur in the muscles of the 
pharynx ; the abnormal mov^ements are synchronous with 
the respiration, and manifest themselves as rhythmic inspira- 
tory contractions of the two posterior pillars of the fauces, 
usually accompanied by simultaneous contractions of the 
adductor muscles of the vocal cords. Hysteric motor dis- 
turbances in the larynx chiefly affect the muscles concerned 
in phonation. As we have previously stated, the participa- 
tion of the abductors in the loss of phonation or a convul- 
sion, as assumed by Przedborski,^ has not been proved. 
The most important symptom of these affections is the 
hysteric aphonia, a simple disturbance of coordination in 
which there is imperfect coaptation of the adductor mus- 
cles and inability to maintain the tension necessary for 
the voice production. The laryngoscopic image is sub- 
ject to enormous variations, and we find in hysteria every 
alteration in the shape of the glottis that can possibly 
be conceived as produced by the failure in action of indi- 

1 "D. Arch. f. klin. Med.," xni, p. Il8. 

2 See " Semon's Centralbl.," x, p. 39. 

3"Th^se de Montpellier," Jan. 9, 1891 ; "Semon's Centralbl.," ix, 
p. 96. 

* " Die Bewegungsstorungen im Kehlkopfe bei Hysterischen," Jena, 1895. 
5"Mon. f. Ohr.," 1885, No. 11. 



HYSTERIA. 303 

vidual groups of muscles. Thus, we get the picture of 
paralysis of the internus, of isolated paralysis of the inter- 
arytenoideus, of the lateral crico-arytenoid, or of the thyro- 
arytenoid muscles, or various forms of paralysis combined, 
so that, for instance, the action of the interarytenoid and 
of the lateral crico-arytenoid muscles may be in abeyance. 
These associated palsies of the adductors are particularly 
characteristic of hysteria and are rarely found in other 
diseases. That these hysteric disturbances do not corre- 
spond to palsies in the ordinary sense of the term is shown 
by the fact that during the examination the vocal cords 
often approximate almost to the point of contact at the first 
attempt at phonation, and then immediately separate and 
assume a position simulating one of the forms of paralysis 
mentioned ; that is to say, the muscles do not lack the 
faculty to perform the movements, but there is a psychic in- 
ability to perform the desired act. This finds further con- 
firmation in the remarkable phenomenon that hysteric sub- 
jects, although incapable of uttering a single word in a loud 
voice, often phonate or cough during the laryngoscopic 
examination, or regain their power to speak in their dreams 
or during hypnosis ; while even a greater paradox is pre- 
sented by those cases in which the singing voice is perfectly 
preserved while there is complete aphonia. 1 Spasm of the 
glottis and so-called laryngeal cough are occasionally ob- 
served, and are to be regarded as spastic phenomena or 
hyperkinetic motor neuroses. This hysteric cough and 
other laryngeal noises (bruits larynges), which may have 
the sound of bleating, howling, or grunting, are described 
by Charcot. 2 Characteristic features are their recurrence 
at definite hours and their complete cessation during sleep. 
The cough or other noises may occur only once or be 
repeated several times in rhythmic order ; dyspnea or 
apnea never occur, no matter how often the attacks may 
be repeated. There are no objective signs in the larynx or 
in the lungs, and it is noteworthy that the condition is not 
accompanied by any other hysteric symptoms, unless there 
be certain disturbances of sensation and of special sense, 
such as anesthesia and diminution in the field of vision. 

1 Griffen, see " Semon's Centralbl.," x, p. 312. Gerliardt, " Kehlkopf- 
geschwiilste," etc., Nothnagel's "Spec. Path. u. Ther.," vol. xiil, 2. Th., 
2 Abth., p. 50. 

2 " Med. du syst. nerv.," 11, p. 443. 



304 NERVOUS DISEASES. 

All these forms of hysteria occur, either suddenly, under 
the influence of fright, traumatism, etc., or develop gradu- 
ally. The nature of hysteria is such that any peculiar 
movement that has once been executed under the influence 
of some momentary external agency persists as the effect 
of a morbid imagination (Treupel). As the disease does 
not depend on any material alterations, the line of treat- 
ment is clearly indicated ; an attempt should be made to 
free the patient from the morbid impression that he is un- 
able to use his voice, and the normal power of the muscles 
should be restored by systematic exercise of the voice and 
■of the respiration. Moritz-Schmidt^ divides hysteric palsies 
into three grades, on a purely external practical basis, as 
follows : 

First, cases in which the voice may have been lost for 
some time, immediately reappears on laryngoscopic exam- 
ination, but is lost immediately afterward. 

Second, cases in which the voice does not appear during 
examination and the patient whispers. 

Third, cases in which the patient can not even whisper 
— a condition which has been designated apsithyria. 

A single case of motor disturbance in the muscles of the 
ear, consisting in contractions of the tensor tympani, and 
giving rise to subjectiv^e cracking noises, has been reported.^ 
Among other manifestations of hysteria hemorrhages from 
the ear have been mentioned. As the cases referred chiefly 
to females, or persons suffering from neurasthenia as the 
result of masturbation, we refer to the chapter on the sexual 
organs for these affections. 

Certain neurasthenic and hysteric conditions which are 
produced by traumatism and very frequently give rise to 
disturbances in the ear are closely allied to hysteria. Ob- 
servations have been reported in regard to ear disease in 
" railway spine," 3 and in regard to traumatic hysteria of 
the ear * 5 after a stroke of lightning, while innumerable 
hysteric and neurasthenic symptoms following injuries of 
the head have been reported. The diagnosis often pre- 
sents the greatest difficulty to the physician on account of 



1 Second Edit., p. 706. 

2 Freund u. Kayser, "Deutsche med. Wochen. ," 1891, No. 31. 
* Baginsky, " Berlin, klin. Wochen.," lS88, No. 3. 

5 Freund u. Kayser, " Deutsche med. Wochen.," 1891, No. 31. 
•*«' Arch. f. Ohr.," vol. xxix, p. 327, and vol. xxxviii, p. 102. 



HYSTERIA. 305 

the want of any definite objective findings. Where no ex- 
ternal injury is visible, the patients usually complain of 
increasing difficulty of hearing and tinnitus aurium. Ver- 
tigo, which is usually absent in hysteria, is conspicuous in 
these cases, but it is not at all clear that the symptom is 
due to a lesion in the ear itself The results of the func- 
tional test are often the same as in hysteria. It is often 
extremely difficult to interpret them correctly, both because 
the patient is in a state of mental excitement and gives 
contradictory and unreliable answers, and because the deaf- 
ness can not, as a rule, be ascribed with absolute certainty 
to the traumatism, as it is a well-known fact that the hear- 
ing is very apt to be affected in traumatic neurasthenia 
with the remains of an old aural disease. 



APPENDIX. 



NASAL REFLEX NEUROSES. 

Since the ground was broken by the works of Hack 
the doctrine of nasal reflex neuroses has received general 
recognition, and thus it may be said that another morbid 
process has been added to the domain of pathology. As, 
however, Hack in his first publications gave such a liberal 
interpretation to the concept of nasal reflex neurosis that 
experienced observers were led to warn the profession 
against a too general application of his propositions, and 
other authors after Hack in their uncritical laxity extended 
the range of reflex neuroses almost indefinitely, it seems 
well to define what is meant by reflex neuroses and their 
v^arious forms as determined by the results of accurate ex- 
perimentation. 

Among the reflex conditions which can with certainty be 
attributed to irritation of the nasal mucous membrane we 
include sneezing, trifacial cough, spasm of the glottis, and 
asthma. In addition, there may be some effect on the ac- 
tion of the heart, but here we must take into account the 
possibility of vasomotor disturbances, such as the so-called 
vasomotor coryza and " hay fever." Our physiologic in- 
vestigations of these reflexes are based on the inves- 
tigations of Francois Franck which have been utilized 
more than any others in the following description. The 
sensory nerves of the nasal cavity are derived from the tri- 
facial. The anterior ethmoidal nerve, a branch of the nasal 
nerve of the first division, supplies the anterior portion of 
the nasal cavity corresponding to the external nose, while 
the remaining portion of the interior of the nose is supplied 
by the posterior nasal branches of the second division, and 
by a branch of the dental nerve of the third division. 

These nerves transmit the nasal reflexes which are known 
as sneezing, nasal cough, and reflex spasm of the glottis. 

The sneezing reflex may be produced in any part of the 
306 



SNEEZING REFLEX. ASTHMA. 307 

nasal mucous membrane, as any one can convince himself. 
The anterior and posterior extremities of the middle and 
inferior turbinals, and the corresponding parts on the septum, 
are said to constitute a special irritative zone, as the reflex 
is most easily produced in these regions. The sneezing 
reflex may also be produced by irritation at some distance, 
which is transmitted to the nasal cavity through the chan- 
nels of the trifacial nerve. Everybody is familiar with the 
production of the nasal reflex by sudden illumination of the 
eye, such as occurs when we look into the sun, the re- 
flex in this case being carried from the ciliary to the an- 
terior ethmoidal nerve by way of the nasal nerve. The 
sneezing can usually be prevented by exerting pressure on 
the trunk of the ethmoidal nerve at a point where it is 
superficial, as on the inner upper wall of the orbit and at the 
lower border of the nasal bone, where the external branch 
leaves the inner surface of the nasal cavity, between the 
bone and the cartilage. The reflex act of sneezing itself is 
effected by the respiratory muscles, and consists in a deep 
inspiration followed by a sudden explosive expiration with 
the glottis widely gaping and the soft palate shutting off 
the oral cavity from the nasopharynx, so that the entire 
respiratory blast escapes through the nose under high 
pressure. 

The "nasal cough," and the reflex convulsions of the 
glottis and of the bronchi in the form of spasm of the 
glottis and asthma, represent various grades of a reflex 
action transmitted through the same channels. The im- 
pulse travels toward the center along the channels of the 
trigeminus, and returns toward the periphery in those of 
the vagus. Franqois Franck and Lazarus have furnished 
exact experimental proof of this reflex. By irritating the 
nasal mucous membranes it is possible to constrict the 
lumina of the bronchi, but as soon as the vagus is excluded 
the experiment becomes impossible. The marked contrac- 
tion of the bronchial muscles may even give rise to visible 
retraction of the intercostal spaces (Franqois Franck). The 
spasmodic nature of this reflex from the nasal mucous 
membrane may manifest itself in spasm of the glottis as 
well as in asthmatic S}'mptoms. The latter is to be regarded 
as a combination of all the forms now under discussion, 
and was observed in animals, A\'liic]"i, after irritation of the 
nasal mucous membrane with the gal\-anocautery, fell to 



308 APPENDIX. 

the ground in a condition of asphyxia, with respiration 
arrested either in inspiration or in expiration, and recovered 
very slowly. Milder grades of the attack showed them- 
selves more in a change of the respiratory rhythm and 
general restlessness of the animal. 

The nasal reflex neuroses manifesting themselv^es in car- 
diac affections in the form of retardation of the pulse and 
cardiac arhythmia have also been proven by direct experi- 
mentation. Another group of reflex neuroses, revealing 
themselves clinically in swelling and redness about the nose 
and eyelids and in headache and vertigo find their physio- 
logic explanation in the vasomotor disturbances produced 
in the nose. To this class belong the vasomotor secretory 
neuroses which are described as vasomotor coryza, hydror- 
rhea of the nose, and hay fever. Their etiology is usually 
not ascertainable ; most likely they represent a reflex neu- 
rosis which any accidental external factor may induce in 
hysteric and neurasthenic subjects. It is not as yet gen- 
erally admitted that hay fever belongs to this group. It is 
possible that paralysis of the sympathetic may also produce 
hydrorrhea of the nose, although the hypothesis is not 
confirmed by experience. In one case of unilateral paraly- 
sis of the cervical sympathetic I observed that the erectile 
tissue in the turbinals was more swollen on the diseased, 
than on the sound side, but there was no nasal secretion, 
and the swelling yielded promptly to cocain. Finally, we 
must include in this group the reflexes transmitted to the 
sexual apparatus from the nose, since they are to be 
regarded in the main as the effect of vasomotor irritation. 

We distinguish two kinds of vasomotor disturbances of 
nasal origin, one of which manifests itself in the erectile 
tissue and mucous membrane of the nose itself, while the 
other finds expression in the vessels of other organs when 
the sensory nerves of the nose are irritated. The reflexes 
of the first variety are chiefly vasodilator in character, such 
as we see after probing a normal nasal mucous membrane. 
The reflexes of the second group, on the other hand, 
present various characters. Thus, Franqois Franck found 
that irritation of the nasal mucous membrane produced a 
dilatation in the vessels of the head and a constriction in 
the superficial and deep vessels of the extremities. 

We often see the statement that reflex neuroses may be 
produced by the sense of smell, and the literature co'ntains 



OLFACTORY REFLEXES. 3O9 

a large number of cases in which the perception of certain 
odors was followed by reflex conditions. One woman was 
attacked with sneezing fits whenever she smelled roses ; 
another whenever she was exposed to the foul smells of 
manure from a horse or cow stable ; epileptic and asthmatic 
attacks, and even reflex irritation of the genitalia through 
the olfactory nerve, have been described, and the sexual 
excitement induced by smelling the opposite sex has even 
been interpreted as a reflex. For the first group effected 
through the sense of smell we must assume an idiosyncrasy 
depending on hysteric predisposition, while the second form 
can be explained on psychologic grounds only. The scent- 
ing of the opposite sex evokes not a reflex, but a sensuous 
excitation analogous to that conveyed through the eye or 
the ear; instance the call of the male to the female among 
animals. 

When we attempt to explain the production of a change 
in the respiratory rhythm, which appears to be the effect of 
reflex irritation through the olfactory nerve, we meet with 
a greater difficulty. Gaule,^ however, suggests that the 
change in the respiratory rhythm is not so much a reflex 
act of the organism to protect the body against the invasion 
of deleterious substances, as it is an effort to adapt the res- 
piration to the act of smelling. 

It follows from these considerations that the existence of 
nasal reflex neuroses now rests on a firm theoretical basis, 
instead of, as formerly, on mere clinical observation consist- 
ing chiefly in post hoc propter hoc arguments, such as im- 
provement after local treatment of the nose. But to be 
quite exact, we should in addition demand an absolute 
clinical proof for all nasal reflexes, viz., that they can only 
be produced from the nasal mucous membrane, that they 
may be completely arrested by anesthetizing the mem- 
branes, and that they can only be finally cured by direct 
treatment of the offending spot in the nasal mucous mem- 
brane. These points should be particularly insisted upon 
in the diagnosis of all doubtful cases. 

Hack uttered the opinion in his first publication that the 
reflexes can only be produced from certain definite regions 
in the nasal mucous membrane corresponding to the posi- 
tion of the erectile tissue. He set up the hypothesis that 

1 Heymann's " Ilandb. der Laryng.," vol. ni. 



3IO APPENDIX. 

the irritation of the sensory nerve endings of the nasal 
mucous membrane is secondary to the sweUing and en- 
gorgement of the erectile tissue, so that the reflex is not due 
to the primary cause but to the irritation of the nerve end- 
ings by the swollen erectile tissue. This theory was an- 
tagonized by Frankel and others, and it has now practically 
passed into oblivion. Yet it appears to throw some light 
on certain doubtful points, for, as pointed out by Hack, it is 
a well-known fact that the reflexes are less likely to be pro- 
duced by chronic catarrhal conditions associated with great 
hyperplastic swelling than they are by the milder hyper- 
emic processes, inducing an intermittent swelling of the 
nasal mucous membranes which would be more likely to 
irritate the nerve endings. 

But we can dispense with this artificial theory of Hack's 
by laying down the maxim that reflex neuroses are most 
apt to occur when opposing regions of the mucous mem- 
brane periodically come into contact with one another, 
nasal respiration, being still intact. 

This intermittent contact is lost when the adjoining 
regions are brought into constant apposition by conditions 
of hyperplasia or by the formation of large polypi. Such 
an irritation is possible in any part of the nasal mucous 
membrane where the lateral wall is capable of touching the 
median wall, and it is not necessary to limit its predilection 
to the region of the erectile tissue. It is true that contact 
will occur most frequently between the inferior and middle 
turbinate bones, where the embedded erectile tissue on one 
side impinges on the other, on the tubercle of the septum, 
a condition favorable for the development of such hyper- 
emia. 

The individual shape of the interior of the nose also 
plays an important role. Thus a marked deviation, or a 
spine or crest on the septum approaching the lateral nasal 
wall favors a periodic contact between the opposed mucous 
membranes even when the swelling is very slight. 

In the etiology of nasal reflex neuroses we must not 
neglect those conditions in which slight hyperplastic pro- 
cesses are found at the anterior extremity of the middle 
turbinate bones without any other pathologic conditions 
in the nose, or the presence of small nasal polypi just 
beginning to grow from the middle turbinate in the 
middle meatus. In this case the reflex neuroses appear 



SUPPURATION. PERTUSSIS. 3 I I 

to be produced by contact of the hyperplastic mucous 
membrane with the free border of the inferior turbinated 
bone. 

Another etiologic factor in the production of nasal reflex 
neuroses is said to be found in adhesions between adjoining 
portions of the nasal mucous membrane and in distortions 
and overstretching of the membrane by the contraction of 
cicatricial tissue. It is also quite conceivable that the con- 
tinued presence of a foreign body in the nose might lead to 
reflex neuroses by irritation of the sensory nerves. 

An important role in the production of the clinical picture 
which we are considering must be conceded to suppura- 
tions within the nose originating in adjacent cavities. We 
must mention in particular suppuration in the antrum, 
especially in those cases where, owing to a marked alteration 
in the region of the middle meatus, there is only a slender 
stream of pus in the middle meatus to indicate the disease. 
In these cases the nerve endings in the mucous membrane 
are irritated by the pus which enters through the nasal 
orifice of the respective cavity and, by moistening the sur- 
rounding mucous membrane, materially affects its nutritive 
conditions, as is shown by the polypoid hypertrophies pro- 
duced in the later stages of the disease. 

Finally, we must emphasize that a nervous disposition is 
necessary for the production of the nasal reflex. The nasal 
mucous membrane is in a condition of abnormal excitability 
in which a mild irritation, such as in the healthy subject 
would produce only a slight swelling of the nose, is capable 
of evoking a whole complex of reflex phenomena. While 
the pungent odor of certain substances, such as flowers or 
agricultural products or the inhalation of smoke and dust- 
laden air, produces in a healthy man only the normal 
reflexes, consisting in swelling of the mucous membrane, 
increased secretion, and the act of sneezing, the same in- 
fluences in the hypersensitive mucous membrane of hysteric 
and neurasthenic persons suffice for the development of 
pathologic reflexes manifesting themselves in cough, asthma, 
or even in the symptom-complex of hay fever. 

It is worth mentioning that pertussis has also been re- 
garded as a reflex neurosis derived from the nasal mucous 
membrane, and it is said that the attacks can be consider- 
ably mitigated by cocainizing that structure. 

In connection with the nasal reflex neuroses we must 



312 APPENDIX. 

refer to certain conditions which are usually included among 
them, but really only represent the sequelae of interference 
with nasal respiration ; they are not the effect of reflex 
irritation, but are produced mechanically by interference 
with nasal respiration and the secondary changes in the 
organism. In these conditions we do not have to deal 
with a neurosis which can be shown to follow irritation of 
certain regions of the nasal mucous membrane, nor with a 
neurosis which can be suppressed by cocainizing the re- 
spective regions in the nasal mucous membrane. They 
represent rather the expression of insufficient respiration 
and defective oxidation of the blood, and may present 
themselves under a great variety of forms. 

It is hardly necessary to say that we must carefully 
guard against too liberal a construction of the significance 
of nasal stenosis. The most frequent manifestation is that 
known as aprosexia, which can be seen characteristically in 
children suffering from adenoid vegetations. Enuresis 
nocturna, chorea, and epilepsy have also been included 
among the ultimate effects of nasal stenosis, but great care 
should be enjoined in interpreting such cases, remembering 
that very often a few accurate observations are obscured and 
vitiated by subsequent carelessly reported cases, and thus 
the whole doctrine discredited. 

Under the name of aprosexia {a-poniyziv zw vcDv) Guye ^ 
has described a clinical picture consisting of inability to fix 
the attention on one subject, of unusual forgetfulness mani- 
festing itself in the rapid disappearance of mental impres- 
sions which originally were acquired only at the expense of 
great effort, and finally of headache, which in some cases 
was limited to a feeling of constant or intermittent pres- 
sure in the head, while in others it produced all the phe- 
nomena of violent hemicrania, especially during the morn- 
ing hours. 

According to Guye, we should distinguish three varieties 
of aprosexia, the first of which is physiologic and the effect 
of overexerting the brain ; the second, neurasthenic, as a 
consequence of pathologic brain fatigue ; while the third 
represents the nasal aprosexia, now under discussion. 

It arises in consequence of nasal stenosis associated with 
swelling and stasis in the venous and lymphatic channels of 

1 " Deutsche med. Wocben.," 1S87, No. 43, and 18SS, No. 40. 



APROSEXIA. ENURESIS. 313 

the nasal mucous membranes. The pathogenesis of. apro- 
sexia is readily understood when we consider the intimate 
relation existing between the lymphatic spaces and . blood- 
vessels of the nasal mucous membrane and the subarach- 
noid space. Schwalbe and Retzius were able to inject the 
lymphatic vessels of the nasal mucous membranes through 
the arachnoid space. An equally intimate relation exists 
between certain venous regions of the nose and the interior 
of the skull, although in this case the blood stream which, 
according to Zuckerkandl, is directed brainward, does not 
suggest stasis in the intercranial venous channels so much 
as an engorgement of the nasal veins with stagnant venous 
blood containing a large percentage of CO 2- 

Enuresis nocturna occurs with comparative frequency in 
children suffering from obstruction of the nose due to 
adenoid vegetation or other causes. Gr6nbech,i how- 
ever, believes that the cases are probably due to a certain 
disposition to enuresis, since adenoid vegetations are very 
common, and the combination of enuresis with nasal ob- 
struction ought therefore to be observed much more fre- 
quently. 

The most familiar, and at the same time most plausible 
hypothesis, is that the relation between the two diseases 
depends on an excessive amount of CO 2 in the blood due 
to defective respiration, as a result of which there is a mild 
degree of carbonic acid poisoning, which in turn leads to 
relaxation of the vesicle sphincters. 

A simpler explanation is that the enuresis is due to the 
fact that the children are restless and only half asleep in 
consequence of the defective respiration. It is often found 
in connection with pavor nocturnus (terror infantium) in 
mouth-breathers, and is explained by the fact that sleep is 
frequently interrupted by cessation of the breathing due to 
reflex closure of the mouth. 

In rare cases, choreic movements, especially of the face, 
— as, for instance, wrinkling of the brow or twitching of 
the corners of the mouth, — are described. Tic convulsif 
and epileptiform conditions have been attributed to nasal 
obstruction. Although we usually find the note that 
removal of the cause of the nasal stenosis, such as 
adenoid vegetation or hypertrophies of the mucous mem- 

1 "Arch. f. Laryng.," Ii, p. 224. 



314 APPENDIX. 

brane, was followed by cessation or diminution of these 
" reflex conditions," the cases can not be accepted without 
a reservation, as the causal relationship between nasal 
stenosis and such convulsions is still very obscure. 

Occasionally examination of the nose or other minor 
nasal operation is followed by a partial epileptic attack of 
syncope similar to its epileptic equivalent, by sudden ex- 
citement, or by temporary unconsciousness ; such con- 
vulsive attacks are not to be regarded as reflex phe- 
nomena, they are the product of a violent psychic irri- 
tation in subjects of a neurasthenic or hysteric disposition. 
I have, however, seen a true epileptic attack produced in 
an epileptic subject by endonasal interference. 



THE SIGNIFICANCE OF SOME OF THE CRANIAL NERVES 
IN RHINOLOGY AND OTOLOGY. 

The Trifacial Nerve. 

The trifacial nerve is the sensory nerve of the mucous 
membrane of the nose and of its accessory cavities, and is 
therefore involved in any diseases affecting these structures. 
Hence nasal diseases are frequently accompanied by neu- 
ralgia and reflex phenomena conveyed through the 
branches of this nerve. The nasal reflexes have been 
mentioned, and in speaking of diseases of the eye it has 
been said that irritation of the anterior ethmoidal nerve and 
of the nasal branches of the second division of the trifacial 
in the interior of the nose may give rise to reflex epiphora. 
We will now consider exclusively the sequelae which take 
the form of neuralgia. 

Supra-orbital neuralgia is a frequent symptom of disease 
of the frontal sinuses. Both acute rhinitis with inflamma- 
tion of the mucous membrane in the accessory cavity, and 
acute or chronic suppuration of the frontal sinuses may 
lead to a typical neuralgia of the first division of the fifth 
nerve. The implication of the nerve finds a general expla- 
nation in the fact that branches of the supra-orbital extend 
to the anterior and lower wall of the frontal sinus, and may 
thus transmit the pain of an inflammation to the trunk of 
the nerve ; but, in addition, certain individual anatomic 
conditions play an important role, since the distance of the 
supra-orbital nerve from the walls of the cavity varies with 
the dimensions of the frontal sinus. 



TRIFACIAL NEURALGIA. 3 I 5 

The symptoms of a neuralgia secondary to disease of 
the frontal sinus are the same as those of simple neuralgia. 
Points of tenderness are found at the supra-orbital foramen 
and at the inner upper angle of the orbit where the 
ethmoidal nerve leaves that cavity. There is tenderness 
of variable degree at the anterior lower wall of the frontal 
sinus, while epiphora and slight edema of the upper eyelid 
occur, with lancinating, often periodic pains radiating 
toward the forehead and occiput. These symptoms may be 
either unilateral or bilateral, depending on the nature of 
the primary disease. 

When the neuralgic symptoms predominate in the clinical 
picture, a diagnosis is usually impossible without a nasal 
examination until circumscribed edema and bulging of the 
orbital or anterior wall of the frontal sinus make their 
appearance, when even the general practitioner who is not 
versed in rhinology can no longer entertain a doubt of the ex- 
istence of suppuration in the frontal sinus. It can not be 
denied, however, that even the rhinologic examination is not 
always absolutely clear, as simple catarrhal changes of the 
nasal mucous membrane may occur in primary trifacial 
neuralgia as the effect of a reflex vasomotor and trophic 
disturbance. The nasal condition establishes the diagnosis 
when the neuralgic pains are associated with discharge of 
pus from the middle meatus or with hypertrophic or 
polypoid changes in the neighborhood of the hiatus semi- 
lunaris and on the middle turbinated bone. 

Neuralgia of the infra-orbital nerve may occur in connec- 
tion with disease of the antrum of Highmore. The canal 
for the transmission of the nerve fills the upper (orbital) 
wall of the cavity and projects sharply into the lumen, 
while its numerous dental branches course along the inner 
surface of the lateral wall in minute grooves covered only 
by the mucous membrane of the sinus. Although the 
infra-orbital nerve is nearer to the antrum of Highmore 
than is the supra-orbital nerve to the frontal sinus, neuralgia 
of the inferior orbital nerve is rarer than supra-orbital 
neuralgia. This is perhaps explained by the drainage con- 
ditions of the cavity and the location of the nerve at the 
roof, while in the frontal sinus the retention of pus frequently 
leads to such an increase of the pressure as to cause bulg- 
ing of the walls of the cavity. This increase of pressure 
rarely occurs in empyema of the antrum — disregarding 



3i6 APPENDIX. 

cysts ;and, tumors which give rise to different appearances, — 
as the communication between the cavity and the nose, 
although situated somewhat high and affording incomplete 
drainage, is still much more free than that of the frontal 
sinus, which is situated in the narrow infundibulum of the 
hiatus semilunaris. Hence pressure on the nerve canal or 
on the nerve itself, if the canal is gaping, is not likely to 
occur. But if there is marked retention, the pressure 
manifests itself chiefly on the floor rather than against the 
orbital wall, and a bulging of the lateral wall of the cavity 
is much more likely to ociur as it is in part membranous 
and corresponds to the lateral wall of the nose. 

As the dental branches from their superficial position 
are more exposed to disease, the inflammation may spread 
from them to the nerve-trunk and give rise to typical neural- 
gia, or at least to tenderness at the point of exit of the 
infra-orbital nerve. 

Griinwald^ states that the sphenopalatine ganglion, on 
account of its close proximity to the anterior and inferior 
walls of the sphenoidal sinus and the ethmoidal cell, is 
liable to become involved in caries of these bony cavities. 

In neuralgia of the first division there is a point of ten- 
derness on the external nose where the external branch of 
the anterior ethmoidal nerve passes out between the nasal 
bone and the lateral cartilage to the skin covering the tip 
of the nose. 

During operations on the septum and on the nasal floor, 
the pain often radiates to the upper incisors and to the 
anterior part of the hard palate, owing to the distribution 
of the terminal branches of the nasopalatine nerve of Scarpi 
which leaves the nasal cavity through the incisor foramen 
to reach the oral cavity. 

The relations between the trigeminal nerve and the organ 
of hearing consist in : 

(i) Disturbances in the ear in disease of the trigeminus 
and its branches ; and, 

(2) Disturbances of the trigeminus in diseases of the 
ear. 

The organ of hearing receives sensory nerves from the 
trifacial, the auricle and external auditory meatus being 
supplied by the auriculotemporal nerve, a branch of the 

1 " Die Eiterungen der Nase," 2d ed., p. 125. 



TRIFACIAL NEURALGIA. "OTALGIA." 317 

third division, while another branch running from the small 
superficial petrosal to the tympanic plexus along the med- 
ian wall of the tympanum effects a connection between the 
trifacial and the tympanic plexus by means of the otic gan- 
glion. 

Otalgia is a favorite but very misleading term for all kinds 
of earache. It is, of course, convenient, and as it is a very 
general expression, it does not commit one to anything, so 
that it is often used to describe any obscure symptom. It 
w^ould be well, however, to use the expression otalgia as a 
diagnostic term only when it is synonymous with neuralgia 
otitica or neuralgia tympanica, affections which point to 
implication of the trifacial and of its aural branches. 

These neuralgias occur most frequently in caries of the 
upper or lower molars. Korner ^ gives as a symptom of 
this form of otalgia which is often difficult to distinguish 
from toothache : an increase of the pain in the ear when the 
gland between the lower jaw and the hyoid bone is pressed 
upon. 

Similar pains are complained of in diseases of the articu- 
lation of the jaw which are variously described as rheuma- 
tism (Schwartze^), or neuralgia (Bruck^). From my own 
observation of a similar case I know how difficult it is to 
interpret the earache correctly, and it may often be impos- 
sible to determine whether there is an otalgia due to radia- 
tion of the pain through the branches of the trifacial, or 
whether the pain in the joint is erroneously referred to the 
ear. 

The distribution of the trifacial is also responsible for the 
radiation to the ear of pains which have their origin in the 
nasopharynx, the pillars of the fauces, the lateral wall of 
the pharynx, and the base of the tongue. Neuralgic 
pains in the ear occurring in connection with disease of the 
epiglottis and of the larynx are probably transmitted by the 
pneumogastric through its auricular branch, which is one 
of the sensory nerves of the external ear. 

It would take too long to enumerate all the diseases 
capable of producing neuralgia of the ear in this way. The 
commonest of them are ulcerations, acute inflammations, 
angina (especially tonsillar abscess), and inflammation and 

1 "Zeitschr. f. Ohr.," XXX, p. 133. 

2 " Die chir. Krankh. des Olires. " 

^ "Deutsche nied. Wochen.," 1895, No. ;i2- 



3l8 APPENDIX. 

swelling of the base of the tongue and of the epiglottis. 
Finally, "otalgia" has long been known as a characteristic 
sign of carcinoma of the larynx. 

In trifacial neuralgia the pain frequently radiates to the 
ears, or may even be especially marked in the auriculotem- 
poral nerve. Krepuska ^ met with a case of primary sar- 
coma of the Gasserian ganglion which began with obstinate 
neuralgia. Lesions of the nucleus or trunk of the trifacial 
nerve produce anesthesia of the external auditory meatus 
and of the auricle. The eruptions of herpes zoster which 
occasionally become localized in the auricle may perhaps 
also be referred to this innervation. 

As the tensor tympani muscle is innervated by a motor 
branch of the trifacial which is given off from the otic 
ganglion, we should expect to find interference with this 
muscle in disease of the trifacial nerve. It is, however, 
very difficult to prove that such is actually the case, as we 
possess no reliable means of distinguishing the functions of 
the internal muscles of the ear. The functional disturb- 
ances which result are very slight, for paralysis of the 
muscle does not affect the general power of hearing ; it 
only induces hyperesthesia to very high tones, while a 
contraction of the muscle diminishes the vibrations of the 
ossicles and increases the pressure in the labyrinth. Clonic 
spasms of the tensor tympani, in which the tensor veli 
palati usually participates, manifest themselves as cracking 
noises in the ear ; they were first described by Schwartze.- 

Extirpation of the Gasserian ganglion or of the second 
or third divisions of the trifacial nerve, now quite fre- 
quently done for therapeutic purposes, should afford us 
a means of studying the function of the muscle, but the 
observations in this respect have so far been ver)^ disap- 
pointing. In the case published by Krause, ^ the hearing 
was not affected unfavorably by extirpation of the Gasserian 
ganglion, and in the case reported by Aster "* from Czerny's 
clinic, of resection of the second and third division of the 
fifth nerve, the hearing remained intact for three weeks 
after the operation, when another complication occurred 
which will be referred to later. The only phenomenon 

1 Krepuska, " ZeitscVir. f. Ohr.," xxx, p. 189. 

2 " Arch. f. Ohr.," II, 4. 

* " Miinch. med. Wochen.," 1S95, Xos. 26 and 27. 

* " I'.eitr. z. klin. Chir.," XI, 3 Heft. 



EXTIRPATION OF GASSERIAN GANGLION. 319 

that may perhaps be regarded as the result of paralysis 
of the tensor tympani is that described in one of Krause's 
cases. The patient complained of a peculiar sensation 
in the temporal region which she compared to the tick- 
ing of a watch, and which, she said, she had never ob- 
served before the operation. But as this phenomenon is 
rather a symptom of clonic muscular cramp or irritation of 
the trifacial than of a paralysis, it is difficult to establish 
any causal relationship between it and the extirpation of 
the nerve. Moos ^ believes that the hyperesthesia of the 
trifacial nerve may, without the motor branches being 
involved, lead to auditory disturbances in the form of 
abnormal sensitiveness to certain kinds of tones and noises, 
and explains the phenomenon as due to an increased tactile 
sensibility of the external auditory meatus to the unusual 
sound waves ! Whether the tinnitis aurium which accom- 
panies toothache is due to reflex muscular irritation or to 
vasomotor influences has not as yet been determined. 
Schwartze ^ explains it as a reflex irritation of the auditory 
nerve through the trifacial, but the explanation does not 
seem very clear to me. 

Urbantschitsch^ reports a series of observations which 
have been interpreted as the effect of reflex irritation of the 
sense of hearing from various regions supplied by the tri- 
facial nerve. 

The conditions found after extirpation of the Gasserian 
ganglion fail to confirm the observation of various authors, 
based on experimentation, that lesion or division of the 
trunk of the trifacial nerve sets up an inflammatory process 
in the mucous membrane of the tympanum, designated by 
Berthold ^ ^ as otitis media neuroparalytica. The latter 
authority claims that lesions of the trifacial, either in its 
continuity or in the roots, may produce all stages of inflam- 
mation in the middle ear from simple vascularization to 
suppuration, and Baratoux ^ found that this was confirmed 
by his experiments ; while Kirchner, '^ after dividing the 
inferior dental nerve in a cat, and subjecting it to 

1 "Virch. Arch.," vol. Lxviii. 

2 "Berlin, klin. Woclien.," 1S66, Nos. 12 and 13. 
^ " Lehrb.," p. 349. 

* " Schwartze's Handb.," p. 315. 

5 "Zeitschr. f. Ohr," x. 

6 "Arch. f. Ohr.," XIX, p. 199, 200. 

'' " Mon, f. Ohr.," 1SS2, No. 4, and comp. "Arch. f. Ohr.," xx, p. 58. 



320 APPENDIX. 

electrical irritation, observ^ed a more marked dilatation 
of the vessels in the tympanic cavity and increased 
secretory activity of the mucous membrane. We may dis- 
regard those cases in which toothache was followed by 
acute exudative middle-ear catarrh (Walb), or those in 
which paralysis of the trifacial was followed by more or 
less complete deafness, as the connection between the two 
diseases is not clearly shown. In fact, the opposite appears 
to be proved by Krause's cases, in which extirpation of the 
trifacial had no effect on the power of hearing. Asher's 
case can not, I think, be used in the evidence ; a serous 
exudation in the middle ear associated with chronic catarrh 
of the nasopharnyx developed three weeks after resection 
of the second and third divisions of the trifacial nerve. 

As neuralgia of the ear may be due to diseases of the 
trigeminal nerve, conversely this nerve may become impli- 
cated in diseases of the ear. The trunk of the trigeminal 
nerve may suffer in endocranial complications of middle-ear 
disease, in pachymeningitis, in extradural abscess, and in 
serous and purulent meningitis. Phlebitis of the cavernous 
sinus gives rise to neuralgia of the first division of the fifth 
nerve (Korner ^). 

As the Gasserian ganglion is situated in Meckel's recess, 
on the upper surface of the petrosal portion of the temporal 
bone, a purulent otitis media may, by extension toward the 
apex of the petrous portion, lead to marked nutritive dis- 
turbances, involve the Gasserian ganglion and produce 
trifacial neuralgia, as was first described by v. Troltsch ^ 
and Schwartze,^ and later by Habermann. 

Chorda Tympani. 

Lesion of the chorda tympani gives rise to disturbances 
in the sense of taste in the anterior two-thirds of the tongue, 
and as the nerve passes through the tympanum * and is 
exposed to injury by any pathologic process present in that 
cavity, it deserves special mention. 

The chorda tympani is given off from the facial nerve a 

1 " Otit. Hirnerkrankungen," 2d edit., 1896, p. 67. 

2 " Arch. f. Olir.," iv, p. 126. 

3 " Arch. f. Ohr.," xui, p. iio. 

* Comp. V. Frankl-Hochwart, Nothnagel's "Spec. Path. u. Therap.," vol. 
XI, II, Th. 4. Abth. " Die nervosen Erkrankungen des Geschmacks," etc., 
the literature will be found best in Urbantschitsch, " Lehrb. der Ohrenheilk." 
and in " Schwartze's Handb.," i, p. 468. 



CHORDA TYMPANI. 321 

little above the point where the latter leaves the tympanum. 
It reaches this cavity through a special opening in its bony 
wall, and after sweeping from behind forward and upward 
between the long process of the incus and the handle of 
the malleus, partially covered by the posterior ventricular 
fold, passes through the Glaserian fissure to reach the base 
of the brain, and is continued from that point to the lingual 
nerve of the third branch of the trifacial, with which it 
becomes united. 

Although a branch of the facial, it really belongs to the 
trigeminus, from which it is originally given off, and only 
accompanies the facial for a short distance. As it is proven 
that injury of the facial above the geniculate ganglion has 
no effect on the sense of taste, the fibers of the chorda 
tympani may leave the facial either by way of the great, or 
by way of the small superficial petrosal nerve. But as this 
point is still in dispute, opinions are divided as to whether 
the chorda tympani belongs to the second or to the third 
division of the trifacial ; if to the former, the nerve runs from 
the great superficial petrosal nerve through the Vidian to the 
sphenopalatine ganghon ; if to the latter, from the small 
superficial petrosal nerve to the otic ganglion. 

The innervation is even more complicated, and the symp- 
tom of loss of taste at the tip of the tongue becomes more 
obscure, when we remember that the path of the fibers of 
taste is a variable one ; they may pass directly from the 
chorda tympani to the otic ganglion without passing through 
the facial nerve, or they may join the facial after its exit 
from the stylomastoid foramen without utilizing the chorda 
tympani. The first mode of distribution may be inferred 
when a lesion of the facial in the temporal bone between 
the geniculate ganglion and the region of the chorda tym- 
pani does not affect the sense of taste ; the latter, if a lesion 
of the facial, external to the stylomastoid foramen, is followed 
by loss of the sense of taste. 

The conditions being thus inconstant, we can not wonder 
that the functional disturbances which occur after destruc- 
tion of the chorda tympani during its course through the 
middle ear do not tally with our expectations. The state- 
ments of a patient are of no value in the determination of 
the frequency with which disturbances of the sense of taste 
occur in middle-ear disease when the chorda tympani is 
destroyed, for we know by experience that such disturbances 

21 



322 APPENDIX. 

may often escape detection even in those who are given to 
observing themselves most carefully. Thus Carl, ^ who 
had suffered from purulent otitis media for many years, was 
very much astonished when he one day discovered that he 
had entirely lost the sense of taste in the anterior portion 
of the tongue ; and the investigations of Urbantschitsch,^ 
who made a careful examination of 50 patients suffering 
from middle-ear diseases — mostly chronic suppurations, — 
and found that 46 were suffering from a gustatory disturb- 
ance, go to show that, unless a special examination has been 
made with a view to determine the presence of such a dis- 
turbance, case histories are of no value in determining 
the frequency of its occurrence. Carl observed sharp 
stinging sensations on the left margin of the tongue, begin- 
ning at about the middle and shooting to the tip with 
lightning rapidity, thus corresponding to the distribution of 
the chorda tympani ; the pain occurred whenever he cleaned 
his ear with cotton pledgets or irrigated it with astringents 
and salicylic acid. 

While we are on the subject of gustatory disturbances due 
to diseases in the middle ear, we must not omit to mention 
those which occur after injury of the tympanic plexus in 
the distribution of the glossopharyngeal nerve. 

The tympanic plexus is formed by the terminal branches 
of Jacobson's nerve, a branch of the glossopharyngeal, and 
connects with the trifacial and facial nerves and with the 
sympathetic caroticotympanic plexus. Owing to the con- 
nection of Jacobson's nerve, which is given off from 
the petrosal ganglion, with the small superficial petrosal 
nerve, this plexus contains both gustatory fibers from the 
petrosal ganglion through the glossopharyngeal nerve, and 
gustatory fibers from the otic ganglion through the trifacial, 
so that one would expect disturbances of the sense of taste 
after lesions of the tympanic plexus, and they have in fact 
been lately reported by Schlichtling ^ from Korner's clinic. 

According to Urbantschitsch and others,"* the secretion 
of saliva may be affected by chemic or mechanical irritation 
of the tympanic plexus and of the chorda tympani either 



1 "Arch. f. Ohr.," X, p. 163. 

2 " Anoraalien des Geschmack," Stuttgart, 1876 (from quotations in Urbant- 
schitsch's " Lehrb. der Ohrenheilk." and elsewhere). 

3 " Zeitschr. f. Ohr.," xxxii, p. 3S8. 
* " Schwartze's Handb. ," i, p. 471. 



FACIAL NERVE. 323 

during medication (alum, salicylic acid, etc.), or during 
instrumental treatment (probing), or by inflammations of 
the nerves in purulent otitis media, as the nerves which 
supply the parotid gland are derived from the sympathetic 
and glossopharyngeal, while those which supply the other 
salivary glands are found in the chorda tympani. 

Facial Kerve. 

As the facial and auditory nerves are united in their 
course as far as the internal auditory meatus, they are often 
attacked by the same disease. Hence the combination of 
central facial paralysis with nervous auditory disturbance 
may afford a valuable hint for the localization of an endo- 
cranial lesion. 

The facial nerve has other important relations with the 
organ of hearing, inasmuch as it is the motor nerve for the 
muscles of the ear. 

The muscles of the auricle and the stapedius muscle are 
supplied by the facial nerve, and their function is therefore 
impaired in any paralysis of the facial situated centrally, or 
originating in the respective muscular branches. 

Paralysis of the posterior auricular nerve, which supplies 
the occipital muscle and the retrahens, attrahens, and attpl- 
lens aurem muscles, manifests itself in immobility of the 
auricle, and according to Erb ^ may indicate whether the 
seat of the paralysis is above or below the region of this 
nerve, which leaves the facial after its exit from the stylo- 
mastoid foramen. Patients suffering with facial paralysis 
frequently complain of tinnitus aurium and difficult hear- 
ing. As the stapedius muscle is supplied by the facial 
nerve, the symptom is usually referred to paralysis of the 
nerve, and Asher ^ saw this confirmed anatomically in a 
case of facial paralysis due to direct pressure of a cerebral 
tumor in the occurrence of atrophy of the stapedius muscle. 

According to Gottstein,^ Hitzig was the first to point 
out that patients suffering from peripheral facial paralysis 
experience a loud buzzing noise in the ear whenever they 
attempt to move the paralyzed half of the face, because the 
voluntary impulse, being unable to innervate the muscles 
of the face, expends all its force on the branch to the sta- 

1 "Arch. f. klin. Med.," xv, p. 22. 

2 "Zeitschr. f. klin. Med.," vol. XXVII. 

3 " Arch. f. Ohr.," xvi, p. 61. 



324 APPENDIX. 

pedius muscle which is still intact. In a number of Erb's 
cases, and occasionally in the latest literature, these patients 
complain of certain auditory disturbances which they de- 
scribe as hyperacousis (oxyocoia), tinnitus aurium, and 
heightened electrical irritability of the auditory nerve. 

It is, however, more than doubtful whether all these 
phenomena can be referred to the stapedius muscle, and we 
can not lose sight of the possibility that the auditory nerve 
itself may be involved on account of its proximity to the 
facial. 

Buzzing noises in the ear on the paralyzed side in per- 
ipheral facial paralyses are probably always to be referred to 
abnormal activity of the stapedius muscle. 

Hyperacousis or oxyocoia can be referred to the loss of 
function of the stapedius muscle which, according to 
Lucae,! accommodates the ear to the highest known 
musical tones, and paralysis of which is followed by ab- 
normal perceptive power for deep notes and increased 
sensitiveness to all musical tones and similar sounds, par- 
ticularly for deep tones, so that if the noises are at all loud 
they may produce a sensation of pain. 

In regard to increase in the electrical irritability of the 
auditory nerve, there is an observation by Seterblad '^ which 
is often quoted, but has never been confirmed by anybody 
else. 

We may also mention another aural symptom in facial 
paralysis ; it is the prodromal pain in or behind the auricle 
which, according to Oppenheim,^ may appear even when 
the paralysis does not originate in the ear. 

The facial nerve, from its close proximity to the auditory 
and its passage through the temporal bone, comes into 
very close relations with the organ of hearing. It ac- 
companies the auditory nerve from its exit at the medulla 
oblongata as far as the internal auditory meatus ; hence 
facial paralyses due to lesion of this portion of the 
nerve-trunk are frequently accompanied by auditory nerve 
deafness. Among the causes which may produce such 
lesions, tumors and aneurysms at the base of the brain, 
basal meningitis, syphilitic pachymeningitis, and gummata 
are the most frequent. 

1 "Berlin, klin. Wochen.," 1874. 
* "Zeitschr. f. Ohr.," xvi, 292. 
3 " Lehrb. der Nervenkrankh." 



FACIAL NERVE. 325 

After leaving the auditory nerve in the inner meatus, the 
facial continues its course in the Fallopian canal, and at the 
geniculate ganglion turns backward and downward, cross- 
ing the posterior portion of the median wall of the tympanic 
cavity, and finally, after passing downward along the floor 
of the posterior wall of the external auditory meatus, leaves 
the skull through the stylomastoid foramen. 

During its course through the petrous portion of the 
temporal bone the nerve is well protected, and is therefore 
little exposed to diseases other than tumors and traumatic 
fractures of the bone. Hence such a paralysis is an im- 
portant sign of disease in the internal ear. The nerve is 
most exposed to disease during its passage through the 
middle ear. 

Facial nerve palsies are often observed in acute inflamma- 
tions of the middle ear, and are explained by extension 
of the inflammation either through the openings which 
exist in the canal of the facial nerve for the passage of the 
nerve to the stapedius and the chorda tympani, or through 
congenital clefts which not infrequently expose the nerve at 
different points in the middle ear. It has also been stated 1 
that a facial paralysis may be caused by inflammatory 
hyperemia in the domain of the stylomastoid artery, which 
supplies both the tympanic cavity and the auditory nerve. 
The danger to the nerve is of course enormously increased 
if the suppuration in the middle ear is associated with 
carious disease of the bone, as such a complication leads to 
sequestration of the bony wall of the facial canal. Injury 
of the facial during operations can be avoided if the surgeon 
possesses any knowledge of the anatomic relations of the 
nerve and even a moderate experience in operative technic. 
Nevertheless, they are seen only too frequently after extir- 
pation of the petrous portion of the temporal bone and 
radical operations. 

DISEASES OF THE MENINGES AND OF THE CEREBRAL 
SINUSES. 

Their Significance in Connection with the Nose, Lar- 
ynx, and Ears. 

Diseases of the meninges may involve the cranial nerves 
and thereby produce pathologic conditions in the organs 
under discussion. 

^ Schwartze, " Die chirurg. Krankli. desObres," p. 174. 



326 APPENDIX. 

Such changes have been observed in pachy- and lepto- 
meningitis and in tubercular and syphilitic meningitis, and 
recently the opinion is becoming more and more prevalent 
that serous meningitis is often responsible for palsies of the 
cranial nerves. Thus, paralysis of the vocal cords has been 
observed in various diseases : in epidemic cerebrospinal 
meningitis irritative conditions in the muscles of the larynx 
may occur, as observ-ed by Oppenheim (quoted by Kraus), 
along with irregular twitchings in the lower distribution 
of the facial nerve, in the uvula, and in the vocal cords, 
taking the form of continuous rhythmic and isochronous 
contractions in the vocal cords. Occasionally olfactory 
disturbances are reported as signs of involvement of the 
olfactory nerve, but the most frequent sequelse of diseases 
of the meninges are found in lesions of the auditory nerve 
or of the labyrinth. Hence, in any case of greatly dimin- 
ished hearing or deafness acquired in early youth, we 
should always take into account the possibility of an ante- 
cedent inflammation of the meninges if there is no history 
of an infectious disease. 

The aural disturbance may originate in disease either of 
the auditor)^ nerve or of the labyrinth, since it is well known 
that the sheath of the auditory nerve and the aqueducts of 
the vestibule and of the cochlea present a natural pathway 
for the spread of the disease from the interior of the 
cranium to the internal ear. 

In cases where it is doubtful whether the seat of the 
aural disturbance is to be sought in the trunk of the auditory 
nerve or in the labyrinth, a coexistent facial paralysis may 
point to the localization of the lesion in that part of the 
trunk of the acusticus which lies in close proximity to the 
seventh nerve. 

Among the diseases of the meninges acute cerebrospinal 
meningitis plays a very important role, and I take up the 
consideration of this disease now rather than among the 
infectious diseases, because it gives rise for the most part 
to the same varieties of secondary disease of the cranial 
nerves as a meningitis due to other causes. 

We learn from studies on the etiology of epidemic cere- 
brospinal meningitis that the nose plays an important part 
in the genesis of the disease, the meningococcus intercel- 
lularis (Weichselbaum) being constantly found in the nose 
and its accessory cavities. Although the significance of 



EPIDEMIC CEREBROSPINAL MENINGITIS. 327 

this bacteriologic finding is somewhat weakened by the fact 
that Schiff 1 found virulent cocci in 4 out of 28 cases of 
persons who were not suffering with epidemic cerebrospinal 
meningitis, it is nevertheless probable that infection very 
frequently takes place through the nose, because the disease 
often begins with coryza (Striimpell) ; and we have 
Weigert's ^ authority for the statement that catarrhal in- 
flammations are frequently found in the accessory cavities 
of the nose at the autopsy. 

It is quite possible that the ear as well as the nose may 
in some cases afford entrance to the pathogenic micro- 
organisms of acute cerebrospinal meningitis. The menin- 
gococcus intercellularis has, indeed, been found in isolated 
cases in the aural secretion, ^ but not with sufficient 
frequency to warrant a general conclusion as to its primary 
significance in the production of a secondary meningitis. 
As pointed out by Leyden * and Schwabach, ^ purulent 
otitis media occasionally coexists with the general disease, 
so that the thought naturally suggests itself that both 
affections are produced by the same pathogenic micro- 
organism. Schwabach was able to prove in one case, in 
which the internal auditory meatus and dura mater were 
found to be entirely free from pus at the autopsy, that the 
suppuration of the middle ear was not a secondary inflam- 
mation due to extension from the cerebrum. 

Purulent otitis media is, however, comparatively rare as 
a complication of acute cerebrospinal meningitis, and far 
less frequent than the other form of the disease which is 
due to direct extension of the purulent process from the 
meninges to the internal ear. 

It has been proved by numerous anatomic investigations ^ 
that the inflammation extends either along the sheath of 
the acusticus or through the aqueducts of the labyrinth 
where the purulent or hemorrhagic inflammatory process 
is followed by extensive tissue-destruction. As we have 
just stated, the suppurative process in the middle ear often 
begins in the first stage of the systemic disease ; the deaf- 
ness which must be attributed either to suppuration within 

1 "Centralbl. f. inn. Med.," 1898, No. 22. 

2 " Deutsche Arch. f. khn. Med.," xxx. 

3 Froniann, " Congr. f. inn. Med.," 1897. 

•* Nothnagel's " .Spec. Path. u. Therap. ," vol. X. 

5" Zeitschr. f. klin. Med.," xvni. 

" Comp. Moos, " Schwartze's Handb.," I, p. 575. 



328 APPENDIX. 

the labyrinth or to disease of the nerv^e-trunk occurs either 
in the course of the disease or as a sequel. 

The impairment of hearing, which is often accompanied 
with vertigo and vomiting, symptoms due probably to im- 
plication of the vestibular segment of the labyrinth, pre- 
sents no definite characteristic, but usually goes on pari 
passu with the rapid extension of the alterations in the 
middle ear and labyrinth, and attains a very high grade in 
a few days. Often it goes on to total deafness, affecting one 
or both ears, and may even render the patient deaf and 
dumb, because the rav^ages of the disease are usually so 
great that the power of hearing can not be restored. The 
statistics in deaf and dumb asylums present convincing 
proof of the prominent part taken by acute cerebrospinal 
meningitis in the medical history of their inmates. 

Diseases of the Meninges in Nasal Affections. 

There have been reported in the literature a small number 
of cases in which disease of the meninges followed disease 
of the nose and of its accessoiy cavities. The cases have 
been collected by Griinwald ^ and Dreyfuss,^ the most fre- 
quent diseases being purulent meningitis, cerebral abscess, 
and thrombosis in a sinus, especially in the cavernous sinus. 
The number is, however, very small, and the cases lack 
uniformity. Hence it will be impossible to show the ex- 
istence of a definite relationship, as will be seen to be the 
case in otitic cerebral diseases. Therefore it is not alto- 
gether Dreyfuss' fault that he failed in his attempt to give 
a systematic presentation of " diseases of the cerebrum and 
its adnexa following suppurations in the nose," ^ in spite of 
his perseverance and industry in looking up all the literature 
bearing on the subject. 

The interior of the cranium ma}' become infected either 
from the nose or from its adjacent cavities. In the former 
case, infection is transmitted by the lymphatic and vascular 
channels, which, as we have repeatedly stated heretofore, 
establish an intimate relationship between the upper seg- 
ment of the nasal cavity and the anterior fossa of the cere- 
brum. Thus all kinds of inflammations, including the 
reactive form due to the use of the galvanic cautery, 
and infectious diseases of the upper portion of the nose, 

^ "Die Lehre von den Naseneiterungen," Munich, 1896, p. 125. 
2 Jena. Fischer, 1896. ^ ^(,^. ^// 



INFECTION FROM THE NOSE. 329 

which approximately corresponds to the ethmoid bone, 
frequently set up an irritative process in the meninges and 
lead to grave constitutional phenomena. Considering the 
frequency of galvanocaustic interference, the cases that go 
on to a purulent meningitis are, however, comparatively 
rare. The latter complication is particularly to be dreaded 
after tamponade of the upper portion of the nose on account 
of the resulting retention of secretion, which is always of 
an infectious nature. The fissures which are said to be 
occasionally present in the cribriform plate of the ethmoid 
bone are, according to Dreyfuss,i of some significance in 
the genesis of rhinitic cerebral complications, but the cases 
of Chiari and Kaiser, on which he bases iiis theory, did not 
appear to furnish a satisfactory proof, and it is difficult to 
believe that "the unfortunate subjects of this anomaly are 
in danger of contracting meningitis after any ordinary 
coryza," and that "even a violent blowing of the nose is 
fraught with great danger in such individuals " (Dreyfuss). 

The second mode of infection of the cerebrum, from 
the accessory cavities of the nose, follows caries of the 
walls of the cavities, a frequent sequel of chronic sup- 
puration. The danger of infection to the brain from 
the diseased cavities necessarily depends on their anat- 
omic relations with respect to the interior of the cranium 
and the thickness of their walls, as in some cases of 
chronic suppuration with caries several cavities are affected 
at the same time, so that it is often impossible to 
determine the exact spot from which the suppuration has 
extended to the cerebrum. The possibility of such an 
etiologic connection must be considered in all diseases of 
the meninges in patients who are the subjects of chronic 
suppuration from the nose. The frontal sinus, the ethmoidal 
cells, and the sphenoidal sinus represent the cavities which 
are in direct relation with the base of the skull, and which 
therefore constitute a more or less serious menace to the 
cerebrum according to the thickness of their walls. 

When, as a consequence of caries, there are evident 
defects in these walls through which the pus can find 
entrance into the interior of the skull, the mode of infection 
is manifest, but there are other cases of purulent menin- 
gitis in which, as I have myself seen, the path followed by 

1 Jena. Fischer, 1896, p. 47. 



330 APPENDIX. 

the pus in traveling from the accessory cavities to the 
serous membranes can not be demonstrated postmortem, 
the bony wall being apparently intact, so that an osteo- 
phlebitis must be assumed to explain the infection of 
the meninges. It would appear from the reported cases, 
including my own, that the sphenoid sinus is most apt to 
transmit the infection, in spite of the thickness of its roof, 
which corresponds with the sella turcica. 

Diseases of the Meninges and of the Cerebral Sinuses 
in Ear Disease. 

The importance of aural disease in the production of 
secondary diseases of the meninges and of the cerebral 
sinuses can not be overestimated, and the doctrine of otitic 
cerebral disease now forms one of the most important 
chapters of otology. 

Since Schwartze introduced operative measures in the 
treatment of ear diseases, since the progress of brain sur- 
gery removed all obstacles in the way of opening the skull, 
since cerebral localization became more and more perfected, 
so that after exposing a morbid focus in the temporal bone 
the extension of the process to the interior of the cranium 
could be observed clinically, the great significance of acute 
and especially of chronic suppurations from the middle ear, 
with accompanying caries of the bone and cholesteatoma 
formation in the production of secondary cerebral disease, 
has won general appreciation. A large proportion of all 
brain abscesses — estimated at one-third — are secondary 
to disease of the middle ear, the infection having been 
carried by means of the diseased meninges. Most cases 
of convex meningitis, of extradural abscess, and of diseases 
of the cerebral sinuses are to be referred to aural disease, 
and the most practical proof of the frequency of otitic 
cerebral complications is found in the great activity of the 
aural surgeons, who, with untiring energy, publish all their 
operative cases. The great number of analogous cases has 
made it possible to determine the pathogenesis and symp- 
toms of these complications. Korner in " Otitic Diseases 
of the Brain, the Meninges, and the Blood-vessels," ^ 
has reduced this doctrine to a system, and this has recently 
been added to very largely by the important contributions 
of Jansen. 

^ Weisbaden, Eergmann, 2d edit., 1S96. 



INFECTION FROM THE EAR. 33 1 

The scope of the present volume does not permit an 
adequate description of the significance of these important 
relations. That belongs to the domain of special text- 
books on otology, and I shall content myself with pointing 
out the channels by which suppurations in the middle ear 
may reach the interior of the cranium, and by describing 
the most important clinical pictures. 

I already touched upon the question of the causal disease 
in cerebral complications when I said that they may be pro- 
duced either by acute or by chronic disease of the ear. 
Among the acute suppurations from the middle ear, the 
most dangerous are those which follow acute infectious 
diseases, such as scarlatina, diphtheria, typhoid, and influ- 
enza, and to these we must add the diseases of the bone 
which often follow acute inflammation in the course of 
diabetes mellitus and tuberculosis, and which from the 
rapidity of their course may reach the interior of the 
cranium in a few weeks. As a chronic otitis media is in 
danger of spreading to the cerebrum, the caution can not 
be too often repeated that removal of a chronic suppura- 
tion, whose destructive effect on the bone can not be 
controlled, is the first law in the treatment of ear diseases. 
If all ordinary means fail, an operation is indicated even 
when its magnitude appears to be out of all proportion to 
the purulent focus in the ear. In many cases the only 
certain means of preventing a threatened cerebral compli- 
cation is to expose freely all the cavities of the tympanum, 
an operation which is quite devoid of danger if the operator 
is faultless in his technic and master of the anatomic 
relations. 

Of all chronic diseases, cholesteatomata are the most dan- 
gerous. Though their progress is slow, they exert a con- 
stant, progressive, destructive influence, and nearly always 
lead to extensive destruction of the temporal bone and 
ultimate exposure of the interior of the cranium. 

The meninges and sinuses are exposed to infection both 
by virtue of their direct contact with the diseased portions 
of the temporal bone and by the possibility of extension of 
a purulent otitis media to the dura through the fissures 
which exist in the bony plates separating the tympanum 
from the interior of the skull, especially in the roof of the 
tympanum. Or the infection may be carried through the 
lab\'rinth after the fenestra; have been destroyed by the sup- 



332 APPENDIX. 

purative process or the external wall of the labyrinth has 
become carious and pierced by fistula;. 

The mode of infection in all those cases in which the 
bone is found diseased up to the point where it comes in 
contact with the dura needs no explanation, but there are 
other cases of cerebral complications in which the bone was 
not found to be diseased up to that point. In explanation 
of such cases Korner has erected an osteophlebitis which, 
as will again be referred to, appears to be of special signifi- 
cance in the production of otitic pyemia. From this point 
of view the fistulas which are often found in the bone run- 
ning to an extradural abscess or to the diseased sinus rep- 
resent periphlebitic blood-vessels. 

The short review which we are about to give of the 
various forms of otitic cerebral disease is based on the 
assumption that the cerebral complication depends on the 
seat and variety of the aural disease, according to which 
the middle ear, the posterior cerebral fossa, the dura mater 
or pia mater will be affected. It also plays an impor- 
tant part in the localization of the secondary cerebral 
abscesses. 

Diseases of the meninges in the middle fossa of the 
cerebrum corresponding to the temporal lobe are undoubt- 
edly due to the passage of pus through the roof of a 
carious tympanum, but the importance of preformed open- 
ings in this plate of bone, which is naturally quite thin, 
has been greatly overestimated. 

The transverse sinus becomes secondarily involved during 
its course within the sigmoid sinus as a consequence of the 
extension of caries of the mastoid antrum and cells to the 
posterior wall of the mastoid process. The danger of this 
complication depends on individual anatomic relations, for 
the course of the sinus varies with the general formation 
of the cranium, as was pointed out by Korner, it being 
more or less superficial and therefore nearer to, or 
farther removed from, the cells in the mastoid process. 
Thrombosis of a sinus is to be attributed to osteophlebitis 
even in those cases in which the caries has not reached the 
sinus (Korner), as the infectious thrombi in the smaller 
blood-vessels in the bone " grow into the sinus." Leutert ^ 
has introduced a new pathologic factor in isolated thrombus 

i"Aich. f. Ohr.." vol. XLi. 



INFECTION FROM MASTOID AND LABYRINTH. 333 

formation, which he found in the bulb of the jugular vein 
and from which he deduced a retrograde thrombosis in the 
sinus. In thrombosis of a sinus there may be extension 
of the thrombus in the opposite direction of the blood 
current in the horizontal portion of the transverse sinus as 
far as the torcular Herophili, and as this leads to occlusion 
of the mastoid artery, there is a swelling over its point of 
exit behind the mastoid process which may be of great 
diagnostic value. The thrombosis spreads to the superior 
and inferior petrosal sinuses, and from them to the cavernous 
sinus, or it may extend downward into the jugular vein, 
but in that case it rarely extends beyond the mouth of the 
facial vein. 

The dura of the posterior fossa of the cranium becomes 
diseased either after caries of the mastoid process or after 
suppuration in the labyrinth. The extension of mastoid 
disease to the dura of the posterior fossa depends on the 
arrangement of the system of cavities and the extent of the 
mastoid cells. As the cells are lined with epithelium, they 
permit the suppurative process to go on rapidly, and if they 
extend as far as the vitreous table, the process spreads more 
rapidly to the interior of the brain than when they are sepa- 
rated from the interior of the skull by a thicker layer of 
compact bone. It is to be remembered that there is a dif- 
ference between adults and young children in this respect, 
as pointed out by Toynbee and later by Jansen.^ As a 
result of the anatomic structure of the mastoid process, 
which in early infancy possesses but few cells arranged in a 
horizontal layer while the posterior wall which separates it 
from the petrous portion of the temporal bone is strongly 
developed, diseases in children up to the age of two years 
tend to invade the cerebrum and the middle, rath'er than the 
posterior, fossa. 

Operations are frequently interrupted by the finding of an 
extradural abscess between the bone and the dura, the 
quantity of pus varying from a few drops to 15 c.c. From 
the expansive pulsation it is easy to recognize the endo- 
cranial origin of the discharge. The dura recedes before 
the pressure of the pus, and an abscess cavity is formed be- 
tween the bone and the dura which leads to compression 
of the cerebral substance, and sometimes attains such 

1 "Arch. f. Ohr.," XXXV, p. 261. 



334 APPENDIX. 

enormous dimensions that the pus makes its way through 
the foramen magnum or the anterior jugular foramen into 
the deep muscles of the neck, or it may burrow along the 
lateral wall and base of the brain and make its way out 
directly through the bone, to form a deep abscess in the 
neck. 

Extradural abscess is usually associated with an accumu- 
lation of pus in the external wall of the sinus, which ex- 
poses the latter to the danger of thrombosis. Although 
both the dura and the wall of the sinus may successfully 
resist this disintegration for a long time, the condition must 
eventually lead to infiltration and the formation of granu- 
lations, which sooner or later bring about the destruction 
of both structures. As, however, the course of the disease 
is very slow, adhesions frequently foi;m between the dura 
and the pia mater and brain substance, thus preventing a 
purulent leptomeningitis. 

Next to thrombosis of a sinus, cerebral abscess is the 
most frequent sequel of extradural abscess ; but after the 
pus has been discharged through the diseased temporal 
bone and the extradural abscess has healed, the path of the 
otogenic infection is withdrawn from clinical observation 
and the interpretation of the abscess becomes, difficult. 

Suppurations in the labyrinth often lead to diseases of 
the dura of the cerebellum, because all preformed openings 
in that situation lead to the posterior fossa. Since the 
recent additions to our knowledge of the involvement of 
the labyrinth in purulent otitis media the significance of 
suppurative processes in the labyrinth in the production of 
otitic cerebral diseases is now better understood (compare 
Jansen and others i). 

Once the pus has reached the labyrinth, it finds many 
channels through which it can enter the interior of the 
cranium, and we can readily understand that it is more 
likely to make its way in this direction than toward the 
middle ear, from which it is separated by the robust wall 
of the labyrinthine capsule. The channels referred to in- 
clude the porus acusticus internus, the aqueduct of the 
vestibule and cochlea, which all have this in common, that 
they open on that surface of the petrous portion of the 
temporal bone which is directed toward the posterior fossa, 

1 "Arch. f. Ohr.," xxxv. 



OTITIC PYEMIA. 335 

SO that, as we have said above, they convey the pus to the 
meninges of the cerebellum. 

Closely connected with the conception of otitic cerebral 
disease is that of otitic pyemia, which occurs in a great 
variety of forms, a distinction being drawn between otitic 
pyemia due to disease of a sinus and otitic pyemia of 
osteophlebitic origin without phlebitis of a sinus, and 
between these and an otitic septicemia. 

If the above-mentioned theory of Leutert, that all cases 
of pyemia are due to the presence of thrombi, however 
minute, within the sinus or the bulb of the jugular vein is 
accepted, the matter is somewhat simplified, as the two first- 
mentioned forms of pyemia — that produced by thrombosis 
of a sinus and that produced by osteophlebitis — are united 
under one head. To reject the existence of an osteo- 
phlebitic pyemia for the sake of justifying this theory, which 
has never been perfectly proven, would be simply to ignore 
the observations of accurate observers. 

It would lead me too far afield to go into the details of 
the similarity of these various forms of pyemia following 
diseases of the ear. In general, it may be said that in a 
sinus pyemia the most conspicuous feature of the clinical 
picture, next to the chills and abrupt rises in temperature, 
are the pulmonary metastases due to emboli from the disin- 
tegrating thrombus ; while in osteophlebitic pyemia the 
fever is high, and shows neither typical chills nor constant 
remissions, emboli are less frequent, and when they do 
occur usually affect the joints and muscles, "as the micro- 
organisms which get into the circulation in osteophlebitis 
are not incased in large portions of thrombic tissue, and 
are therefore easily able to pass through the lungs, until 
they are arrested somewhere in the capillary system of 
the systemic circulation " (Korner). Otogenic septicemia, 
finally, presents all the appearance of general sepsis such as 
we are accustomed to see in grave infections of the entire 
organism. If the habit of making a routine examination 
of the ear in all cases of septicemia could be formed, the 
practice would unquestionably result in a marked limitation 
of our present vague conception of cryptogenetic septi- 
cemia (septicopyemia). 



INDEX. 



Abscess, 333 

cold, of the posterior pharyngeal 
wall in caries of the vertebrae, 
162 
extradural, in aural diseases, 334 
tuberculous, of the thyroid carti- 
lage, 154 
Acid, salicylic, effects of, on the ears, 
248 
on the pharynx and larynx, 
247 
Acids, toxic effect of, on mucous 
membrane of pharynx and larynx, 
242, 243 
Acromegaly, manifestations of, in the 

nose, larynx, and pharynx, 95 
Actinomycosis, laryngeal complica- 
tions of, 186 
of the mouth and pharynx, 185 
Adenoid habit, 42 
vegetations, 41 

mouth-breathing in, 18 
occlusion of the tubes and au- 
ral affections in, 36 
reflex neuroses from, 313 
Adhesions in the larynx from syphil- 
itic ulcers, 218 
in the pharynx, 213 
Air-passages, upper, alterations of, in 
diseases of the lungs, 31 
in diseases of the mediastinum, 

33 
in erysipelas, 147 
in influenza, 132 
in leukemia, 83 
hemorrhages from, in arterio- 
sclerosis, 52 
in cardiac disease, 52 
relation of, to ears, 35 
scleroma of, 31 
significance in respiration, I9 
Alcohol, abuse of, eflect on the or- 
gan of hearing, 250 
on the structure of the pharynx, 
249 
Alkalies, destruction of the pharyn- 
22 



geal and laryngeal mucous mem- 
brane in poisoning by, 242 
Analgesia of the mucous membranes 
of the upper air-passages in hys- 
teria, 297 
Anemia, general, appearances in the 
ears, 82 
in the nose, pharynx, and lar- 
ynx, 81 
of the laryngeal mucous mem 
brane in tuberculosis, 168 
Anesthesia dolorosa, 298 
in hysteria, 297 

of the nose, throat, and larynx after 
diphtheria, 142 
in epilepsy, 294 
in progressive amyotrophic 
bulbar paralysis, 292 
significance of, in inspiration pneu- 
monia, 22 
Aneurysm of the aorta, motor dis- 
turbances of the larynx, 55 
pressure-symptoms in the trachea, 
54 
of the large blood-vessels, subjec- 
tive noises in, 54 
Angina, catarrhal, in acute rheuma- 
toid arthritis, 140 
in measles, 108 
in scarlatina, 1 12 
edematous, after the use of salol, 

247 
uratica, 102 
Anthrax, infection of the nose and 

pharynx in, 1S5 
Antimony poisoning, hoarseness in, 

247 
Antipyrin and antifebrin, olfactory 
disturbances after use of, 247 
tinnitus aurium and difficult hear- 
ing after use of, 248 
Aphasia in diabetic hemiplegia, 96 

uremic, 189 
Aphonia in arsenic eaters, 245 
in Asiatic cholera, 75 
in chlorosis, 81 



337 



338 



INDEX. 



Aphonia in hysteria, 304 

in malaria, 148 
Aprosexia in mouth-breathers, 312 

varieties and pathogenesis, 312 
Arsenic-poisoning, acute and chronic 
ulcers in the external auditory 
meatus in, 245 
nasal and pharyngeal catarrh in, 

245 
Arteriosclerosis, hemorrhages in the 
upper air-passages, 52 
tinnitus aurium, 53 
Arthritis, gonorrheal, of the articula- 
tions of the larynx, 204 
Asthenopia in hypertrophy of the 

turbinates, 230 
Asthma in relation to the nose, 306, 

307 

to the sexual functions, 199 
uremic, differential diagnosis from 

bronchial asthma and laryngeal 

stenosis, 1 88 
Astringents, injurious effect of, on the 

sense of smell, 250 
Atelectasis as a cause of middle-ear 

disease, 50 
Auditory disturbances during men- 
struation and pregnancy, 202 

from increased intracranial pres- 
sure, 268 

in anemia. Si 

in aural tuberculosis, 1 74 

in cerebellar disease, 273 

in disease of the central nervous 
system, 263, 271, 272 

in disease of the meninges, 326 

in epilepsy, 294 

in facial paralysis, 323 

in hysteria, 300 

in intoxications, 242 

in leukemia, 86 

in multiple sclerosis, 290, 291 

in nephritis, 189 

in parotitis epidemica, 138 

in pseudoleukemia, 89 

in syphilis, 220 

in tabes dorsalis,278 

in typhoid fever, 132 

nerve, atrophy of, in amyo- 
trophic bulbar paralysis, 292 
in tabes, 283. 286, 288 

hemorrhage and lymphatic infil- 
tration in leukemia, 84 

neuritis of, from abuse of to- 
bacco, 250 

paralysis of, in hereditary syph- 
ilis, 223 

pathways in the central nervous 
system, 271 



Auditory nerve, reactions of, electric, 
diagnostic significance of, 265 

increased irritability of, 269 

in hysteria, 301 

in rabies, 186 

in strychnin-poisoning, 247 

methods of examination of, 266 

normal formula, 265 
inversion of, 270 

paradoxic, 269, 270 

reflex effect on the movements of 
the eye, 237, 238 



Bacillus mucosus ozoence of Abel, 

46 
Blennorrhea neonatorum as a compli- 
cation in diseases of the nasal mu- 
cous membrane, 226 
Blepharospasm from spasm of the 
stapedius muscle, 240 
in atrophy of the nasal mucous 
membrane and adhesions within 
the nose, 230 
Blood, diseases of, pathologic appear- 
ances in the upper air-passages, 81 
Bronchial glands, diseases of, and 

effect on respiration, 34 
Bronchiectasis as a cause of middle- 
ear disease, 50 
in disease of the upper air-passages, 
28 
Bronchitis after purulent otitis me- 
dia, 51 
capillary, as a cause of aural dis- 
eases, 50 
chronic, in scrofulous children, 29 
fetid, as a sequel of suppuration in 
the accessory cavities of the nose, 
28 
laryngitis and pharyngitis after, 

31 

significance of mouth-breathing in 
production of, 29 
Bronchopneumonia in connection with 

purulent otitis media, 50, 5 1 
Bruits larynges in hysteria, 303 
Bulbar palsy, progressive amyotro- 
phic, laryngeal and aural symp- 
toms in, 293 



Caries of the accessory cavities of 
the nose, etiologic significance in 
diseases of the meninges, 330 

of the temporal bone in tubercu- 
losis, 173 

sicca of the nose in syphilis, 208 



339 



Central nervous system, diseases of, 
as the cause of auditory- 
disturbances, 263 
of laryngeal affections, 
251 
Cerebral disease, otitic, 334 

sinuses, disease of, 325, 328, 330, 

Cerebrospinal meningitis, acute, sig- 
nificance of the nose in, 
326 
of the ear, 327 
deafness in, 327, 328 
in combination with purulent 
otitis media, 327 
Chlorid of zinc poisoning, appear- 
ance of the pharyngeal and laryn- 
geal mucous membrane in, 243 
Chloroform narcosis, effect of, on the 

organ of hearing, 249 
Chlorosis, aphonia in, 81 
Choked disc in chronic middle-ear 

disease, 238, 239 
Cholera Asiatica, effect of, on upper 

air-passages, 75 
Cholesteatoma as cause of cerebral 

disease, 330, 331 
Chondritis laryngea in typhoid fever, 
127 
primary tuberculous, 153 
Chorda tympani, lesions of, in rela- 
tion to sense of touch, 320 
origin and course of, 321 
Chorea minor, motor disturbances of 
the aural and laryngeal muscles in, 
295 
Choreic movements in nasal obstruc- 
tion, 313 
Chronic acid-poisoning, chronic dis- 
ease of the upper air-passages from, 

.243 
Circulatory system, diseases of, in re- 
lation to the upper air-passages, 50 
Cirrhosis of liver, hemorrhages in, 74 
Cohabitation in relation to the nose, 

197 
Condylomata in the auditory meatus 

in syphilis, 219 
Conjunctivitis in scrofulous rhinitis, 

228 
Constitutional diseases, chronic, path- 
ologic alterations of the upper air- 
passages in, 92 
Coordination, disturbances of, in hys- 
teria, 301 
of the laryngeal muscles, disturb- 
ances of, in chorea minor, 295 
Coryza neonatorum in hereditary 
syphilis, 210 



Coryza, vasomotor, 306, 308. (See 
also Hydrorrhea 7iasalis.) 
in malaria, 148 
Cough due to gall-stones, 75 
in nasal affections, 307 
nasal, 306 
trifacial, 307 
Croup, pharyngeal and laryngeal, in 
cholera, 75 



Dacryocystoblennorrhea after 

disease of the nose, 226 
Deafness after embolism of the inter- 
nal auditory artery, prognosis of, 

during menstruation, 203 

in alcohol and tobacco intoxication, 

249_ 
in brain-lesions, 271 
in cerebrospinal meningitis, 328 
in chloroform narcosis, 249 
in combination with subjective 

noises, 64 
in diseases of the meninges, 326 
in epilepsy, 294 
in facial paralysis, 323 
in hysteria, 300 
in lead-poisoning, 246 
in leukemia, 87 
in multiple sclerosis, 203 
in nephritis, 189 

in potassium iodid poisoning, 244 
in quinin and salicylic acid poison- 
ing, 248 
in syphilis, 221 
in tabes dorsalis, 280 
in typhus and typhoid, 131 
postdiphtheric, 146 
Deformities, nasal, in syphilis, 209 
Diabetes mellitus, aural complications 
in, 97 

dryness and atrophy of the oral 
mucous membrane in, 96 

ictus laryngis in, 105 

mastoid disease in, 98 
Digestive organs, diseases of, in re- 
lation to nose, throat, and larynx, 70 
Diphtheria, deafness in, 146 
diseases of the ear in, 143 
in cholera Asiatica, 75 
in measles, 109 
in scarlatina, 1 13 
in typhoid, 126 
postdiphtheric palsies in pharynx 

and larynx in, 142 
Diplococcus pneumonia: in purulent 
otitis media, 49 



340 



INDEX. 



Dyspepsia as a cause of rhinopharyn- 
geal disease, 73 
due to disease of the nose and 
pharynx, 72 
Dyspnea in laryngitis acutica rheu- 
matica, 14I 



Ear, disease of, in connection with 
mastication and deglutition, 
77 

in diphtheria, 143-145 

in infants, 78, 79 

in influenza, 134 

in leukemia, 86 

in malaria, 149 

tubercular, 1 69 
effect of various diseases of the 

respiratory organs on, 47 
embolic disease of, in endocardi- 
tis, 67 
innervation of, 316 
in relation to diseases of the heart 

and blood-vessels, 59 
relation of, to upper air-passages, 

35 
vascular systems of, 60 
Earache, 47. (See also Otalgia.) 
in diseases of the respiratory or- 
gans, 47,48 
Eczema of the nose, 159 

etiologic significance of, in ery- 
sipelas, 147 
in scrofulous children, 160, 193 
Edema of the upper air-passages in 
nephritis, 188 
aural disturbances in, I90 
Emboli in the ear during the puerpe- 

rium, 203 
Emphysema, relation of, to chronic 
catarrh of the upper air-passages, 
28-30 
Empyema of antrum of Highmore, 

70 
Endocarditis, embolic disease of the 

organ of hearing in, 67 
Enteritis in children in connection 
with inflammation and suppuration 
of the middle ear, 78 
Entotic vascular murmurs, character 
of, 61, 62, 65 
differential diagnosis from 
simple noises in the ear, 66 
Enuresis nocturna, etiology of, 313 
Epiglottis, cicatricial changes in 
syphilis, 219 
function and importance of, 28 
in acute rheumatic laryngitis, 140 
in lupus, 175 



Epiglottis in typhoid, 127 

leprosy of, 182 

otalgia in inflammatory swelling of, 
47 

ulcerations of, in foot-and-mouth 
disease, 184 
Epilepsy, symptoms of, in the larynx 

and in the organs of hearing and 

taste, 294 
Epileptic equivalent in nasal obstruc- 
tion, 314 
Epiphora from aural irritation, 240 

from nasal irritation, 240 

in obstruction of the lacrimonasal 
duct, 226 
Epistaxis in arteriosclerosis, 52 

in cardiac disease, 52 

in cirrhosis of liver, 74 

in hemophilia, 89 

in leukemia, ^i'^ 

in malaria, 148 

in purpura hcemorrhagica, 90 

in scorbutus, 91 

in typhoid fever, 124 

seat of, 53 
Erysipelas of the upper air-passages, 

147 
secondary to eczema of nose and 
ears, 148 
Erysipele catameniale, phenomena 

and reflex character of, 199 
Erythema exsudativum multiforme, 
196 
of the larynx, 215 
of the nose, 205, 206 
of the upper air-passages, I93 
syphilitic, of the gums and tonsils, 
210 
Esophagus, diseases of, effect on up- 
per air-passages, 72 
Eunuch voice, etiology and cure of, 

201 
Eustachian tube, dilatation of, in atro- 
phic rhinitis, 45 
functions of, disturbances of, 36 
due to alterations in upper 
air-passages, 40 
occlusion of, 38 

as cause of middle-ear dis- 
ease, 42 
by atrophy of pad of fat, 46 
due to paralysis of muscles of 

soft palate, 43 
in acute and chronic catarrh of 

upper air-passages, 41 
in relation to nasal stenosis, 
42 
significance of, in middle ear, 
37 



INDEX. 



341 



Exanthemata, acute otitis media in, 
44, 109, 116, 119 
manifestations of, in upper air-pas- 
sages in measles, 108 
in scarlet fever, 112, 113 
in varicella and variola, 121 
Exostoses in the external auditory 

meatus in acromegaly, 96 
External auditory meatus, diphtheria 
of, 143 
exostosis and hyperostosis of, 

in acromegaly, 96 
furunculosis of, in diabetes, 96 
hyperesthesia and hyperalge- 
sia of, in hysteria, 298 
in gout, 103 
in syphilis, 220 
pressure variations in, 45 
respiratory murmurs in, 45 
scarlatinal diphtheria of, 118 
skin diseases of, 196 
stenosis of, from syphilitic 

scars, 220 
syphilitic affections of, 219 
Eyes, diseases of, in pathologic condi- 
tions of the nose and its ac- 
cessory cavities, 225 
in alterations in the ear, 235 
reflex disturbances of, movements 
of, from the ear, 237 
in acute and chronic otitis 
media, 239 



Gasserian ganglion, effects of extir- 
pation of, 318 

Gastro-intestinal disease as cause of 
middle-ear disease, 78 

Gingivitis in leukemia, 84 

Glanders, infection through mucous 
membranes of upper air-passages, 

183 

Glottis, spasm of, 306 

hysteric, 307 
Gonorrhea, infection of the nose by 
secretions of, 203 
laryngeal disease in, 204 
Gout, angina uratica in, 102 
aural manifestations in, 103 
changes in the ear in, 102, 104 
in the larynx in, 102, 104 
in the pharynx in, 10 1 
ictus laryngis in, 105 
Gumma in the external ear and mas- 
toid process, 220 
in the larynx, 215, 217 
in the nose, 206 
in the pharynx, 21 1, 212 
Gums, affections of, in leprosy, 181 
in leukemia, 85 
in lupus, 176 
in measles, 108 
in middle-ear disease, 43 
in typhoid fever, 124 
syphilitic, 210, 211 
ulcerative, in foot-and-mouth dis- 
ease, 184 



Facial paralysis, 324 
causes of, 324 
course of, 325 
in middle-ear disease, 325 
localization of lesion in, 323 
Fish-poisoning, appearance of upper 

air-passages in, 248 
Foot-and-mouth disease, catarrh of 
the tubes in, 185 
infection through mucous mem- 
branes of upper air-passages, 
184 
Frontal sinus, neuralgia in, 314 

suppuration of, hyperemia and 
venous stasis of tlie optic pa- 
pilla of the same side in, 233 



Ganglion, Gasserian, in purulent 
otitis media, 320 
sphenopalatine, disease of, in caries 
of the sphenoid and ethmoid 
bones, 316 



Hallucinations, auditory, in abuse 
of alcohol and tobacco, 250 
in chloroform narcosis, 249 
in epilepsy, 294 
Hay-fever, 306, 308 
Heart and blood-vessels, diseases of, 
in relation to the nose, 
pharynx, and laiynx, 52 
to the ear, 59 
lesion, hemorrhages in mucous 
membranes in, 37 
tinnitus aurium in, 60 
Hemophilia, hemorrhages in upper 

air-passages and ears in, 88, 89 
Hemorrhages from the ears in hys- 
teria, 304 
in vicarious menstruation, 201 
in affections of the genitalia, 197 
in cirrhosis of liver, 74 
in hemorrhagic diathesis, 89 
in leukemia, 83, 84, 87, 88 
in pseudoleukemia, 85 
in the middle ear in nephritis, 189 



342 



Hemorrhages in the mucous mem- 
branes of the upper air-passages, 
53 
Hemorrhagic diathesis, 89 
Herpes in ear and external meatus, 
196 
on mucous membranes, 1 94 
Hoarseness from aliuse of alcohol and 
tobacco, 249 
in poisoning with antimony, cop- 
per, and phosphorus, 247 
in syphilis, 213 
Hydrorrhea nasalis in hepatic colic, 

75 
in malaria, 148 
Hyperacousis, 324 

Hysteria, disturbances in the nerves 
of special sense in, 300 
in the ear in, 298 
muscles of, 304 
motor, in larynx, 301 
sensory, in the nose and pharynx, 
297 
Hysterogenetic zones in the mucous 
membranes of the upper air-pas- 
sages, 298 



Icterus in otitis media, 80 

Ictus laryngis in obesity, gout, and 

diabetes, 104 
Influenza, 132 

aural complications in, 134 

laryngitis hemorrhagica, 134 

nasal complications in, 133 

palsies in, 134 

purulent otitis media in, 137 
Inspiration pneumonia, causes of, 27 
Internal ear in influenza, 137 
Intoxications, appearances of, in the 
upper air-passages, 241 

auditory disturbances in, 242 



Jaundice in mucous membranes, 74 



Keratitis, eczematous, in eczema of 
the nose in scrofulous children, 227 

Kidneys, diseases of, 188. (See also 
Nephritis. ) 



Labyrinth, diseases of, 333 
Lacrimonasal duct as a carrier of in- 
fection from the nose to the eye, 
225 



Laryngeal crises in tabes dorsalis, 

278 _ 
Laryngismus stridulus, 93 
Laryngitis acuta rheumatica circum- 
scripta, 141 
hasmorrhagica, 134 
leukemic, 84 
Laryngospasm. {^^& Larynx .") 
Larynx as respiratory pathway, 25 
edema of, after use of potassium 
iodid, 244 
in influenza, 133 
in malarial cachexia, 148 
in nephritis, 188 
in typhoid, 124 
extirpation of, followed by death 

from heart failure, 45 
in relation to diseases of heart and 
blood-vessels, 52 
to nose and pharynx, 18 
paralysis after disease of the lungs, 
32 
from struma, 35 
in cardiac and vascular disease, 

53 
in tumors of mediastinum, 34 
relation of, to diseases of digestive 

organs, 70 
spasm of, 92 
tuberculosis of, 153-158 
ulcers of, anatomic and clinical 
varieties of, 125 
in croupous pneumonia, 31 
in leprosy, 182 
in lupus, 176 

in typhus and typhoid, 1 23 
pathogenesis of, 1 26 
tuberculous, 156 
Lateral sclerosis, amyotrophic laryn- 
geal paralysis in, 293 
Lead poisoning, chronic, manifesta- 
tions of, in the ear, 246 
paralysis of the laryngeal muscles 
in, 246 
Leprosy, early appearances in, 179 
of the ear, 1 83 
of the nasal cavities, 177 
clinical picture, 1 80 
localization of nodes and ulcers 

in, 181 
pathogenesis, 178 
of the pharynx, 181 
transmission of, by nasal secretion, 
179 
Leukemia, 83 

alterations in upper air-passages in, 

hemorrhages in, 83 
manifestations of. in the ear, 86 



INDEX. 



343 



Localization of aural disturbances, 
326 
of the ear in the brain, 270 
of the movements of the vocal 
cords, 258 
Locus Kieselbachii, 53 
Lungs, diseases of, due to disturbances 
in the upper air-passages, 26 
in morbid conditions of upper 
air-passages, 28 
in relation to nose, 19 
Lupus in the upper air-passages, 175 
localization of, 176 
morbid anatomy of, 175 
of the external ear, 177 
of the eye, 228 
of the pharynx, 176 
sequels of, 176 
Lymphomata in pseudoleukemia, 85, 
86 
leukemic, of the internal ear, 87 
of the pharyngeal structures, 84 
Lymphosarcoma, 85 

of the pharyngeal structures, 86 



Malaria, 148 
aphonia in, 149 
epistaxis in, 148 
hydrorrhea nasalis in, 148 
vasomotor rhinitis in, 148 
Malarial disease of the ears, 149 
Mastoid disease as cause of cerebral 
diseases, ^2;^ 
extension of, to dura, ;^^;^ 
in diabetes, 97-99 
syphilitic, 219 
tuberculous, 17 1, 174 
Masturbation, effect of, on existing 
aural disease, 202 
epistaxis in, 197 
tinnitus aurium in, 202 
Measles, 109 

aural complications in, 109-III 
croupous laryngitis in, 109 
Koplick's sign in, 109 
Mediastinum, diseases of, effect on 

respiration, ^^ 
Medulla oblongata, diseases of, motor 
and sensory disturbances in the 
larynx, ear in, 291 
Meniere's symptom-complex in tabes, 
280,' 2S3 
pathogenesis of, 263 
relation of, to gout, 104 
to mumps, 137 
Meninges, diseases of, in connection 
with cranial nerves, 325 
in nasal affections, 328 



Meninges in relation to aural affec- 
tions, 330 
Meningitis, purulent, as cause of 
paralysis of cranial nerve, 326 
in relation to nose, 329 
paralysis of olfactory disturb- 
ances in, 326 
of vocal cords in, 326 
Menstruation, relation of, to nasal 

affections, 197 
Mercurial poisoning, appearances of, 
in mouth and pharynx, 246 
in sound-perception apparatus, 
246 
Middle ear, bacteria in, 44 

catarrh of, acute and chronic, 38 
changes in pressure in, 37 
disease after atelectasis, 50 
after bronchiectasis, 50 
after capillary bronchitis, 50 
diabetic otitis, 99, loo 
in leukemia, 88 
in measles, IIO 
in scarlatina, I18 
in typhoid fever, 129 
diseases of, due to infection from 
postnasal space, 43 
due to obstruction of Eusta- 
chian tube, 41 
hj'drops ex vacuo in, 38 
hyperoemia ex vacuo in, 38 
icterus in otitis media, 80 
inflammatory and noninflamma- 
tory catarrh of, 41 
otitis media sclerotica, 45 
purulent otitis media as cause of 
bronchitis and broncho- 
pneumonia, 51 
as sequel of gastro-intes- 

tinal disease, 79 
in cerebrospinal menin- 
gitis, 327 
in connection with caries 
of the teeth, 77 
with dentition, 77 
in influenza, 137 
in pneumonia, 48 
therapeutic infection of, through 

Eustachian tube, 46 
variations of pressure in, 39 
Miliary tuberculosis, acute, beginning 

in the larynx and pharynx, 154 
Mountain sickness, 40 
Mouth, affections of, gonorrheal, 204 
in actinomycosis, 185 
in foot-and-mouth disease, 184 
in leukemia, 85 
in mercurial poisoning, 291 
in mouth-breathers, 68 



344 



Mouth affections in varicella, 121 
Mouth-breathing as a cause of chronic 
bronchitis, 29 

causes of, 26 

effects of, 26 
Muscular atrophy, progressive spinal, 

laryngeal palsy in, 293 



Nasal douches, dangers of, 46 

proper use of, 47 
Nasalis luetica, 208 
Nephritis, complications of, aural, 
190 
in the upper air-passages. 1S8 
Nervous diseases of the larynx, 251 
of the organ of hearing, 263 
with changes in the nose, throat, 
and larynx, 275 
Neuralgia, infra-orbital, 315 
otitica, 317 
supra-orbital, 314 
trifacial, 314, 315 

in relation to ear, 318 
in sarcoma of the ear, 318 
of Gasserian ganglion, 318 
tympanica, 317 
Neuritis, gonorrheal, of the larynx, 
205 
optica in papillomata of the turbi- 
nates, 231 
Neuroses, involvement of the nose, 

throat, larynx, and ears in, 293 
Nose as respiratory pathway, 20 
bacteria in, 22, 44 
bactericidal power of secretion, 23, 

44 
hydrorrhea of, 308 
innervation of, 306 
in relation to diseases of digestive 
organs, 70 
of the heart and blood-vessels, 
52 
to lungs, 19 
lupus of, 176 

reflex irritation of, from intestines, 
74 
neuroses of, 306 
sneezing reflex, cough, etc., 306 
stenosis of, in relation to occlusion 

of Eustachian tube, 42 
tuberculosis of, 153, 158-161 
eczema in, 159 



Obesity, ictus laryngis in, 104 
Olfactory nerve, hyperesthesia of, in 
epilepsy, 294 



Olfactory nerve, in hysteria, 297 
in rabies, 186 
reflex eftects of, 308 
sense, disturbances of, in anemia, 
81 
function of, in respiration, 24 
Oral cavity, diseases and changes in 
form of, in disturbances of nasal 
respiration, 68 
Ossicles of the ear, caries of, in tuber- 
culosis, 174 
rheumatic disease of, 141 
Osteitis luetica of the nose, 207 
Osteophlebitis as cause of otitic 

pyemia, 332 
Otalgia, 317 

in caries of the teeth, 76 

in diseases of the respiratory organs, 

47 
of the trifacial, 317 
in hysteria, 299 
tympanica in influenza, 137 
Otitis media catarrhalis, 39 

neuroparaiytica, 319 
Oxyocoia, 324 
Ozena, 29 

pathogenesis of, 30 
relation of, to leprosy, 177 
to menstruation, 199 
Ozoena syphilitica, 208 



Palate, paralysis of, in influenza, 
133, 134 
in progressive amyotrophic bul- 
bar paralysis, 292 
occlusion of tube in, 43 
postdiphtheric, 142, 143 
unilateral, in typhoid, 128 
Papillitis nervi optici in purulent otitis 

media, 239 
Papules, syphilitic, in the auditory 
meatus, 219 
in the larynx, 215 
on the gums, 210 
on the nasal mucous membrane, 

206 
on the tonsils, 210 
on the tympanic membrane, 219 
Paralysie glosso-labio-laryngee, 292 
Paralysis agitans, motor disturbances 
of the vocal cords in, 293 
of the recurrent, definition, 54 
from pericardial exudate, 58 
in aneurysm of aorta, 55, 56 
postdiphtheric, I42 
Parasites, intestinal, reflex symptoms 
of, in the nasal raucous membrane, 
74 



345 



Paresis of the vocal cords in laryn- 
geal tuberculosis, i68 
Paresthesia of the upper air-passages 
from sexual excitement, 200 
in amyotrophic bulbar paraly- 
sis, 292 
in chlorosis, 81 
in hysteria, 298 
Parosmia from sexual excitement, 200 
in hysteria, 300 
in influenza, 134 
Parotitis epidemica, 138 
Pericardial exudate, paralysis of re- 
current form, 58 
Perichondritis in typhoid, 134 
laryngeal, in influenza, 134 
nasalis luetica, 207 
syphilitica, 215 
tuberculous, primary, 154 

secondary, 1 66-1 68 
ulcerative, 125 
Pertussis, 311 
Pharyngeal crises in tabes dorsalis, 

279 
Pharyngitis, leukemic, 84 
Pharynx as respiratory pathway, 25 
edema of, in nephritis, 188 
in relation to diseases of the diges- 
tive organs, 70 
of the heart and blood-ves- 
sels, 52 
to larynx, 19 
to nose, 18 
lupus of, 176 

retropharyngeal abscess of, 162 
Phenomena, irritative, in diseases of 
the meninges, 325 
motor, of the laryngeal muscles, 

251 
sensory, in the eyes from irrita- 
tion in the ears, 239 
Phonation, disturbances of, in hys- 
teria, 302 
Pneumonia, laryngeal complications 
in, 32 
purulent otitis media in, 48 
Politzer's method of inflating tym- 
panum, 46 
Posticus paralysis, 256 

in gonorrheal arthritis, 205 
in hysteria, 302 
in syphilis, 219 
in tabes dorsalis, 275 
median position of vocal cord in, 
254, 255 
Pregnancy, aural affections in, 202 

nasal affections in, 197 
Pseudobulbar paralysis, laryngeal 
j^aralysis in, 293 



Pseudoleukemia, 85 

auditory disturbances in, 89 
Puerperium, aural affections in, 202 
Pupil, changes of, from nasal irrita- 
tion, 231 

in purulent otitis media, 239 
Purpura, 89 
Pyemia, otitic, 332-335 



QuiNiN, toxic effect of, on the or- 
gan of hearing, 248 



Rabies, implication of the auditory 
sphere in, 186 
nervous symptoms in, 186 
Rachitis, aural disease in, 95 

laryngeal spasm in, 93 
Raucego syphilitica, 213 
Recurrent paralysis, 252 

cadaveric position of vocal cords 

in, 253, 254.258 
diagnostic significance of, 252 
from pericardial exudate, 58 
in aneurysm of aorta, 54 
in arsenic-poisoning, 245 
in influenza, 135 
in leukemia (tumors), 85 
in mediastinal tumors, 33 
in pulmonary tuberculosis, 33 
in swelling of bronchial glands, 

34 
in tabes dorsalis, 276 
laryngoscopic image in, 253 
stage of posticus paralysis in, 254 
Reflex neuroses, laiyngeal, 106 
nasal, 59, 305 
palpitation of the heart due to irri- 
tation in the nose, 59 
pathogenesis of, 309 
Reflexes of sexual apparatus, 308 

olfactory, 309 
Refraction, errors of, due to nasal 

hypertrophies, 231 
Respiration, changes of pressure in 
the external auditory meatus in, 
37 
nasal, effect of disturbances of, on 

oral cavity, 68 
physiologic pathway of, 20 
preparation of the inspired air, 20 
reflex influence of the olfactory 
_ on, 309 

significance of upper air-passages 
in, 19 
Respiratoiy air current, removal of 
foreign substances and microorgan- 
isms from, 21 



346 



INDEX. 



Respiratory air current, warming and 

saturation of, 23 

murmur, inspiratory and expiratory, 

in the ear, 37 

Retina, peripapillary opacity of, in 

suppuration of the frontal sinuses, 

233 
Rhinitis, acute, in influenza, 132 
atrophic syphilitic, 208 
diseases of the eye in, 226 
fcetida atrophica, 29 
hypertrophic syphilitic, 207 
purulent, from infection with gono- 
cocci, 203 



Saddle-nose, characteristics and 

mode of production of, 209 
Saliva, secretion of, in disease of 

chorda tympani, 323 
Salivation, eftect of irritation of the 
tympanic plexus and chorda tym- 
pani on, 322 
Salol, edematous angina after the use 

of, 247 
Sausage poisoning, dryness of the 

throat and hoarseness in, 248 
Scarlatina, 1 12 

acute otitis media in, 1 18 
aural complications in, 115 
diphtheroid, 113 
Scleroma of upper air-passages, 31 
Scorbutus, 89 

Sensory disturbances of the eyes from 
irritation in the ear, 239 
hysterical, 296 
Septicemia, otogenic, 335 
Septum, nasal perforation of, in 
glanders, 184 
in leprosy, 177 
in lupus, 176 
in tuberculosis, 159 
Sexual functions, reflex effect of, on 

upper air-passages and ears, 197 
Silver-nitrate poisoning, pigmentation 
of the mucous membrane of the 
mouth, tongue, larynx, and tym- 
panic membrane in, 247 
Skin, diseases of, complications of, in 
the external ear and meatus, 
196 
in the upper air-passages, I93 
Sneezing reflex in respiration, 24, 

306, 307 
Speech disturbances in chorea minor, 
.295 

in paralysis agitans, 293 
Spinal cord, diseases of, pathologic 



changes in the nose, throat, larynx, 
and ears in, 275 
Stapedius muscle, eftect of paralysis 

of, 323, 324 
Stomatitis. ( See Month, Affections of.) 
aphthosa epidemica, 1 84 
in leukemia, 85 
Strabismus as a complication of 

hypertrophied tonsils, 230 
Stridor, inspiratory, from enlarged 

thymus, 35 
Struma as cause of tracheal stenosis, 

34 
Sympathetic nerve, paralysis of, etio- 
logic significance in hydrorrhoea 
nasalis, 306 
Syphilis, nervous deafness in, 221, 
222 
of the organ of hearing, 219 

in hereditary lues, 222 
of the upper air-passages, 205 
primary lesion of, in the nose, 206 

in the pharynx, 210 
secondary manifestations, of in the 
larynx, 215, 216 
in the nasal mucous mem- 
brane, 206 
in the pharynx, 210 
tertiary manifestations of, in the 
larynx, 215, 216 
in the nose, 206 
in the pharynx, 211 
Syringomyelia, motor and reflex dis- 
turbances in the larynx and posterior 
wall of pharynx in, 291 



Tabes dorsalis, involvement of audi- 
tory nerve in, 279 
of the laryngeal nerves in, 

275 
of the olfactory nerve in, 275 
Taste, disturbances of, in middle-ear 

disease, 321 
Teeth, diseases of, in relation to 
antrum of Highmore, 70 
to nasal cavities, 71 
Tensor tympani, disturbances of, 318 
Thrombosis of cerebral sinus, 332, 

Thymus gland, alterations of, effect 
on respiration, t^'^^, 35 
as cause of inspiratory stridor, 

35 
as cause of sudden death in 
children, 35 
Tic convulsif due to nasal obstruc- 
tion, 313 



347 



Tinnitus aurium after wounds of the 
head, 62 
caused by pressure on internal 

jugular vein, 67 
in anemia, 62, 81 

and hyperemia within the ear, 
59 
in aneurysm, 62 
in arteriosclerosis, 62, 63 
in disease of heart and blood- 
vessels, 59 
in facial paralysis, 324 
in leukemia, 87 
in sclerosis, 62 

in treatment of heart and lung 
diseases by rarefied and com- 
pressed air, 40 
in variations of atmospheric 
pressure, 40 
Tobacco, abuse of, auditory disturb- 
ances from, 250 
pharyngeal catarrh from, 249 
Tonsils, syphilitic disease of, 210, 21 1 
Toothache distinguished from otal- 
gia, 3^7 
Trachea, changes in, produced by 
aneurysm of the aorta, 57 
pressure ulcers and perforations of, 

57 
pulsating movements of, 57 
rupture into, in aneurysms of aorta, 

52 

stenosis of, 57 

from mediastinal tumors, 34 
from struma, 34 
in aneurysm of aorta, 52 
Transfert of sensory disturbances in 

the ear in hysteria, 299 
Trichinosis, paralysis of laryngeal 
and pharyngeal muscles in, 187 
pharyngeal and laryngeal palsies 
in, 187 
Trifacial, disease of, in relation to the 
ear, 316, 320 
significance of, in rhinology and 
otology, 314 
Tuberculosis, 15 1 
of the ear, 169 
chronic, 171, 172 
diagnostic significance of bacilli 
in, 170 
of the larynx, 153-158, 162-169 
of the nose, 153, 158-161 
of the pharynx, 153, 161 
of the upper air-passages, 151 

mode of infection in primary, 
151 
in secondary, 154 
morbid anatomy of, 151 



Tuberculosis, tonsillar, 152 
Tympanic membrane, respiratory 
movements in, 45 

retraction of, 38 

signs and symptoms of, 38 

rupture of, 39 

sensory disturbances of, in hys- 
teria, 298 

syphilitic papules on, 219 
Typhoid fever, 123 

auditory disturbances in, 132 

aural complications in, 128 

changes in the cartilages of the 
larynx in, 127 

complicated with diphtheria in, 
126 

epistaxis in, 124 

mastoid disease in, 130 

middle-ear diseases in, 129 

palsies in, 127, 128 

pharyngeal and laryngeal catarrh 
in, 124 

ulcers in, 125 



Ulcers, arrosion, tuberculous, of the 
larynx, 156 
localization and pathology 
of, 164 
tubercular, in the larynx, 164 
in the nose, 160 
in the pharynx, 15 1 
Uremia, chronic deafness in, 191 



Valsalva's experiment, 37, 46 
Varicella, 120 
Variola, 121 

aural complications in, 122 

palsies in, 122 
Vasomotor disturbances of nasal ori- 
gin, 307 
varieties of, 308 
Vertigo in anemia, 81 

in leukemia, 87 

laryngeal, 105 
Visual disturbances after operative 

interference in the nose, 231 
Vocal cords, laryngospastic attacks 

of, 55 
movements of, choreic, 295 

localization of, 258 
paralysis of, in disease of the 

liver, 74 
paresis of, in tuberculosis of, 168 
periodic palsies of, 55 



348 



Vocal cords, spasm of, due to seat- 
worms, 74 
tuberculous polyps of, 169 
tumors of, in multiple sclerosis, 
290 
in paralysis agitans, 294 
ulcerations of. in croupous pneu- 
monia, 31 
in leprosy, 182 
in tuberculosis, 1 64, 1 65 



Voice, change of, hyperemia of vocal 
cord in, 200 
pathologic varieties of, 200 
relation of, to puberty, 199 

Vox cho' erica, 75 



Xerosis of the mucous membranes, 
29> 31.45 



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American Students* Medical Dictionary. See page 34. 

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Pyle's Personal Hygiene. See page 34. 

Salinger and Kalteye/s Modern Medicine. See page 34. 

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Senn's Tumors — Second Edition. See page 27. 
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Watson's Handbook for Nurses. See page 31. 
Heisler's Embryology. See page t5. 
Nancrede's Principles of Surgery. See page 20. 
Jackson's Diseases of the Eye. See page 16. 
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Penrose's Diseases of "Women — Third (Revised ) Edition. Page 20. 
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Baldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic, 
etc. Handsome imperial octavo volume of 718 pages, with 341 illus- 
trations in the text, and 38 colored and half-tone plates. Cloth, ^6.00 
net; Sheep or Half Morocco, $7.00 net. Sold by Subscription. 

" It is practical from beginning to end. Its descriptions of conditions, its recommen- 
dations for treatment, and above all the necessary technique of different operations, are 
clearly and admirably presented. . . . It is well up to the most advanced views of the 
day, and embodies all the essential points of advanced American gynecology. It is destined 
to make and hold a place in gynecological literature which will be peculiarly its own."— 
Medical Record, New York. 

AN AMERICAN TEXT^BOOK OF LEGAL MEDICINE AND TOXI- 
COLOGY. 

Edited by Frederick Peterson, M.D., Clinical Professor of Mental 
Diseases in the Woman's Medical College, New York ; Chief of Clinic, 
Nervous Department, College of Physicians and Surgeons, New York ; 
and Walter S. Haines, M.D., Professor of Chemistry, Pharmacy, 
and Toxicology in Rush Medical College, Chicago. In Preparation. 

AN AMERICAN TEXT=BOOK OF OBSTETRICS. 

By 15 Eminent American Obstetricians. Edited by Richard C. Nor- 
Ris, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome 
imperial octavo volume of 1014 pages, with nearly 900 beautiful colored 
and half-tone illustrations. Cloth, ^7.00 net; Slieep or Half Morocco, 
^8.00 net. Sold by Subscription. 

" Permit me to say that your American Text-Book of Obstetrics is the most magnificent 
medical work that I have ever seen. I congratulate you and thank you for this superb work, 
which alone is sufficient to place you first in the ranks of medical publishers." — Alkxander 
J. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y. 

" This is the most sumptuously illustrated work on midwifery that has yet appeared. In 
the number, the excellence, and the beauty of production of the illustrations it far surpasses 
every other book upon the subject. This feature alone makes it a work which no medical 
library should omit to purchase." — British Medical Journal. 

" As an authority, as a book of reference, as a ' working book ' for the student or prac- 
titioner, we commend it because we believe there is no better." — American Journal of the 
M'dical Sciences. 

Illustrated Catalogue of the ''American Text-Books " sent free upon application* 



Medical Publications of W. B. Saunders & Co. 7 

AN AMERICAN TEXT=BOOK OF PATHOLOGY. 

Edited by Ludvig Hektoen, M. D.. Professor of General Pathology 
and of Morbid Anatomy in the University of Pennsylvania ; and 
David Riesman, M. D., Demonstrator of Pathological Histology in 
the University of Pennsylvania. In preparation. 

AN AMERICAN TEXT=BOOK OF PHYSIOLOGY. 

By I o of the Leading Physiologists of America. Edited by William 
H. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop- 
kins University, Baltimore, Md. Second edition, revised and enlarged, 
in two volumes. 

" We can commend it most heartily, not only to all students of physiology, but to ever}' 
physician and pathologist, as a valuable and comprehensive work of reference, written by 
men who are of eminent authority in their own special subjects." — London Lancet. 

" To the practitioner of medicine and to the advanced student this volume constitutes, 
we believe, the best exposition of the present status of the science of physiology in the 
English language." — Atnerican Jourtial of the Medical Sciences. 

AN AMERICAN TEXT=BOOK OF SURGERY. Third Edition. 

By 1 1 Eminent Professors of Surgery. Edited by William W. Keen, 
M.D., LL.D., and J. William White, M.D., Ph.D. Handsome im- 
perial octavo volume of 1230 pages, with 496 wood- cuts in the text, 
and 37 colored and half-tone plates. Thoroughly revised and enlarged, 
with a section devoted to " The Use of the Rontgen Rays in Surgery." 
Cloth, $7.00 net; Sheep or Half Morocco, $8. 00 net. 
«' Personally, I should not mind it being called THE Text-Book (instead of A Text- 
Book), for I know of no single volume which contains so readable and complete an account 
of the science and art of Surgery as this does." — EDMUND Owen, F.R.C.S., Member of 
the Board of Examiners of the Royal College of Siirgeons, England. 

" If this text-book is a fair reflex of the present position of American surgery, we must 
admit it is of a very high order of merit, and that English surgeons will have to look very 
carefully to their laurels if they are to preserve a position in the van of surgical practice." — 
London Lancet. 

AN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE 
OF MEDICINE. 

By 12 Distinguished American Practitioners. Edited by William 
Pepper, M.D., LL.D., Professor of the Theory and Practice of Medi- 
cine and of Clinical Medicine in the University of Pennsylvania. Two 
handsome imperial octavo volumes of about 1000 pages each. Illus- 
trated. Prices per volume : Cloth, ^5.00 net ; Sheep or Half Morocco, 
^6.00 net. Sold by Subscription. 

" I am quite sure it will commend itself both to practitioners and students of medicine, 
and become one of our most popular text-books." — Alfred Loomis, M.D., LL.D., Lro- 
fessor of Pathology and Practice of Medicine, University of the City of Neru York. 

*' We reviewed the first volume of this work, and said : ♦ It is undoubtedly one of the 
best text-books on the practice of medicine which we possess.' A consideration of the 
second and last volume leads us to modify that verdict and to say that the completed work 
is in our opinion tlic best of its kind it has ever been our fortune to see." — New York Medical 
Journal. 

Iflttstrated Catalogue of the "American Text-Books*' sent free upon application. 



8 Medical Publications of W. B. Saunders & Co. 

AN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY. 

A Yearly Digest of Scientific Progress and Authoritative Opinion in all 
branches of Medicine and Surgery, drawn from journals, monographs, 
and text-books of the leading American and Foreign authors and 
investigators. Arranged with critical editorial comments, by eminent 
American specialists, under the general editorial charge of George M. 
Gould, M.D. Volumes for 1896, '97, '98, and '99. One imperial 
octavo volume of about 1200 pages. Cloth, $6.50 net; Half Morocco, 
$7.50 net. Year -Book of 1900 in two volumes — Vol. I., including 
General Medicine; Vol. II., General Surgery. Prices per volume: 
Cloth, $3.00 net; Half Morocco, ^3.75 net. Sold by Subscription. 

" It is difficult to know which to admire most — the research and industry of the distin- 
guished band of experts whom Dr. Gould has enlisted in the service of the Year- Book, oi- the 
wealth and abundance of the contributions to every department of science that have been 
deemed worthy of analysis. ... It is much more than a mere compilation of abstracts, for, 
as each section is entrusted to experienced and able contributors, the reader has the advant- 
age of certain critical commentaries and expositions . . . proceeding from writers fully 
qualified to perform these tasks. ... It is emphatically a book which should find a place in 
every medical library, and is in several respects more nseful than the famous 'Jahrbiicher' 
of Germany." — London Lamet. 

ABBOTT ON TRANSMISSIBLE DISEASES. 

The Hygiene of Transmissible Diseases ; their Causation, 
Modes of Dissemination, and Methods of Prevention. By A. 

C. Abbott, M.D., Professor of Hygiene and Bacteriology, University 
of Pennsylvania ; Director of the Laboratory of Hygiene. Octavo 
volume of 311 pages, containing a number of charts and maps, and 
numerous illustrations. Cloth, $2.00 net. 

THE AMERICAN POCKET MEDICAL DICTIONARY. 

[See Dorlaud' s Pocket Dictionary, page 12.] 

ANDERS' PRACTICE OF MEDICINE. Third Revised Edition. 
AText=Book of the Practice of Medicine. By James M. Anders, 
M.D., Ph.D., LL.D., Professor of the Practice of Medicine and of 
Clinical Medicine, Medico-Chirurgical College, Philadelphia. In one 
handsome octavo volume of 1292 pages, fully illustrated. Cloth, 
^5.50 net; Sheep or Half Morocco, $6.50 net. 

" It is an excellent book, — concise, comprehensive, thorough, and up to date. It is a 
credit to you ; but, more than that, it is a credit to the profession of Philadelphia — to us." 
1 A.MES C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson 
Medical College, Philadelphia. 

ASHTON'S OBSTETRICS. Fourth Edition, Revised. 

Essentials of Obstetrics. By W. Easterly Ashton, M.D., Pro- 
fessor of Gynecology in the Medico-Chirurgical College, Philadelphia. 
Crown octavo, 252 pages; 75 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, 51.25 net. 

[See Saunders^ Questioii-Compends, page 23.] 

*' Embodies the whole subject in a nut-shell. We cordially recommend it to our read 
ers." — Chicago Medical Times. 



Medical Publications of W. B. Saunders & Co. 



BALL'S BACTERIOLOGY. Third Edition, Revised. 

Essentials of Bacteriology ; a Concise and Systematic Introduction 
to the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol- 
ogist to St. Agnes' Hospital, Philadelphia, etc. Crown octavo, 218 
pages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00; 
interleaved for notes, $1.25. 

[See Saunders' Question- Conipends, page 23.] 

" The student or practitioner can readily obtain a knowledge of the subject from a perusal 
of this book. The illustrations are clear and satisfactory." — Medical Record, New York. 

BASTIN'S BOTANY. 

Laboratory Exercises in Botany. Bv Edson S. Bastin, M.A., 
late Prof, of Materia Medica and Botany, Philadelphia College of Phar- 
macy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.00 net. 

**It is unquestionably the best text-book on the subject that has yet appeared. The 
work is eminently a practical one. We regard the issuance of this book as an important 
event in the history of pharmaceutical teaching in this country, and predict for it an unquali- 
fied success." — Alumni Report to the Philadelphia College of Pharmacy. 

BECK ON FRACTURES. 

Fractures. By Carl Beck, M.D., Surgeon to St. Mark's Hospital 
and the New York German Poliklinik, etc. 225 pages, 170 illustratione. 
Cloth, $3.50 net. 

BECK'S SURGICAL ASEPSIS. 

A Manual of Surgical Asepsis. By Carl Beck, M.D,, Surgeon to 
St. Mark's Hospital and the New York German Poliklinik, etc. 306 
pages; 65 text-illustrations, and 12 full-page plates. Cloth, |i. 25 net. 

" An excellent exposition of the ' very latest ' in the treatment of wounds as practised 
by leading German and American surgeons." — Birmingham (Eng.) Medical Review. 

" This little volume can be recommended to any who are desirous of learning the details 
of asepsis in surgery, for it will serve as a trustworthy guide." — London Lancet. 

BOISLINIERE'S OBSTETRIC ACCIDENTS, EMERGENCIES, AND 
OPERATIONS. 
Obstetric Accidents, Emergencies, and Operations. By L. Ch. 

BoisLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis 
Medical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net. 

" A manual so useful to the student or the general practitioner has not been brought to 
our notice in a long time. The field embraced in the title is covered in a terse, interesting 
way." — Yale Aledical Journal. 

BROCKWAY'S MEDICAL PHYSICS. Second Edition, Revised. 
Essentials of Medical Physics. By Fred J. Brockway, M.D., 
Assistant Demonstrator of Anatomy in the College of Physicians and 
Surgeons, New York. Crown octavo, 330 pages; 155 fine illustrations. 
Cloth, 5 1- 00 net ; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Comp ends, page 23.] 

"We know of no manual that affords the medical student a better or more 'Concise 
exposition of physics, and the book may be commended as a most satisfactory presentation 
of those essentials that are requisite in a course in medicine." — New York Medical Journal. 



10 Medical Publications of W. B. Saunders & Co. 

BUTLER'S MATERIA MEDICA, THERAPEUTICS, AND PHAR- 
MACOLOGY. Third Edition, Revised. 
A Text=Book of Materia Medica, Therapeutics, and Pharma- 
cology. By George F. Butler, Ph.G., M.D., Professor of Materia 
Medica and of Clinical Medicine in the College of Physicians and 
Surgeons, Chicago ; Professor of Materia Medica and Therapeutics, 
Northwestern University, Woman's Medical School, etc. Octavo, 874 
pages, illustrated. Cloth, $4.00 net ; Sheep, $5.00 net. 

" Taken as a whole, the book may fairly be considered as one of the most satisfactory* 
of any single-volume works on materia medica in the market." — Journal of the American 
Medical Association. 

CERNA ON THE NEWER REMEDIES. Second Edition, Revised. 
Notes on the Newer Remedies, their Therapeutic Applications 
and Modes of Administration. By David Cerna, M.D., Ph.D., 
formerly Demonstrator of and Lecturer on Experimental Therapeutics 
in the University of Pennsylvania ; Demonstrator of Physiology in the 
Medical Department of the University of Texas. Rewritten and 
greatly enlarged. Post-octavo, 253 pages. Cloth, ^i. 00 net. 

" The appearance of this new edition of Dr. Cerna's very valuable work shows that it 
is properly appreciated. The book ought to be in the possession of every practising physi- 
cian." — Nezv York Medical Journal. 

CHAPIN ON INSANITY. 

A Compendium of Insanity. By John B. Chapin, M.D., LL.D., 

Physician-in-Chief, Pennsylvania Hospital for the Insane ; late Physi- 
cian-Superintendent of the Willard State Hospital, New York ; Hon- 
orary Member of the Medico-Psychological Society of Great Britain, 
of the Society of Mental Medicine of Belgium. i2mo, 234 pages, 
illustrated. Cloth, $1.25 net. 

" The practical parts of Dr. Chapin's hook are what constitute its distinctive merit. We 
desire especially to call attention to the fact that on the subject of therapeutics of insanity 
the work is exceedingly valuable. It is not a made book, but a genuine condensed thesis, 
which has all the value of ripe opinion and all the charm of a vigorous and natural style." — 
Philadelphia Medical Journal. 

CHAPMAN'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. 
Second Edition, Revised. 
Medical Jurisprudence and Toxicology, By Henry C. Chapman, 
M.D., Professor of Institutes of JSIedicine and Medical Jurisprudence 
in the Jefferson Medical College of Philadelphia. 254 pages, with 55 
illustrations and 3 full-page plates in colors. Cloth, §1.50 net. 

"The best book of its class for the undergraduate that we know of." — Neiv York 
Medical Tivies. 

CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. 
Second Edition. 
Nervous and Mental Diseases. By Archibald Church, M. D., 
Professor of Clinical Neurology, Mental Diseases, and Medical Juris- 
prudence in the Northwestern University Medical School, Chicago ; 
and Frederick Peterson, M. D., Clinical Professor of Mental Dis- 
eases, Woman's Medical College, N. Y. ; Chief of Clinic, Nervous 
Dept., College of Physicians and Surgeons, N. Y. Handsome octavo 
volume of 843 pages, profusely illustrated. Cloth, $5.00 net; Half 
Morocco, §6. 00 net. 



Medical Publications of W. B. Saunders & Co. 11 

CLARKSON'S HISTOLOGY. 

A Text=Book of Histology, Descriptive and Practical. By 

Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of 
Physiology in the Owen's College, Manchester; late Demonstrator of 
Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 
22 engravings in the text, and 174 beautifully colored original illustra- 
tions. Cloth, strongly bound, ^4.00 net. 

" The work must be considered a valuable addition to the list of available text books, 
and is to be highly recommended." — New York Medical Journal. 

"This is one of the best works for students we have ever noticed. We predict that the 
book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. 

CLIMATOLOGY. 

Transactions of the Eighth Annual Meeting of the American 
Climatological Association, held in Washington, September 22-25, 
1891. Forming a handsome octavo volume of 276 pages, uniform with 
remainder of series. (A limited quantity only.) Cloth, $1.50. 

COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised. 
Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- 
fessor of Clinical Medicine and Applied Therapeutics in the Philadel- 
phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical 
Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55 
illustrations. Cloth, ^i.oo net. 

[See Saimders^ Question- Compends, page 23.] 

"We can heartily commend the book to all those who contemplate purchasing a 'com- 
pend.' It is modern and complete, and will give more satisfaction than many other works 
which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. 

CORWiN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. 

Essentials of Physical Diagnosis of the Thorax. By Arthur 
M, CoRWiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush 
Medical College, Chicago ; Attending Physician to Central Free Dis- 
pensary, Department of Rhinology, Laryngology, and Diseases of the 
Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, ^1.25 net. 

" It is excellent. The student who shall use it as his guide to the careful study of 
physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good 
working knowledge of the subject." — Philadelphia Folyclitiic. 

"A most excellent little work. It brightens the memory of the differential diagnostic 
signs, and it arranges orderly and in sequence the various objective phenomena to logical 
solution of a careful diagnosis." — Journal of A^ervoiis aiid Mental Diseases. 

CRAQIN'S GYN/ECOLOGY. Fourth Edition, Revised. 

Essentials of Gynaecology. By Edwin B. Cr.-^gin, M. D., Lecturer 
in Obstetrics, College of Physicians and Surgeons, New York. Crown 
octavo, 200 pages; 62 illii^irations. Cloth, $1.00 net; interleaved for 
notes, $1.25 net. 

\?)ee SaunihW Question- Compends, page 23.] 

" A handy volume, and a distinct improvement on students' compends in general. No 
author v\ho was not himself a practical gynecologist could have consulted the student's needs 
so thoroughly as Dr. Cragin has dont."— Medical Record, New York. 



12 Meaical Publications of W. B. Saunders & Co. 

CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. 

A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., 
Professor of Comparative Pathology and Bacteriology, King's College, 
London. Octavo volume of 700 pages, with 273 engravings and 22 
original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. 

" To the student who wishes to obtain a good resume of what has been done in bacteri- 
ology, or who wishes an accurate account of the various methods of research, the book may 
be recommended with confidence that he will find there what he requires." — Lotidon Lancet. 

Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. 
Modern Surgery, General and Operative. By John Chalmers 
DaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery, 
Jefferson Medical College, Philadelphia : Surgeon to the Philadelphia 
"Hospital, etc. Handsome octavo volume of 911 pages, profusely illus- 
trated. Cloth, $4.00 net; Half Morocco, $5.00 net. 

"We know of no small work on surgery in the EngHsh language which so well fulfils 
the requirements of the modern student." — Mcdico-Chirurgical Journal, Bristol, England. 

DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, 
Revised. 
Diseases of the Eye, A Handbook of Ophthalmic Practice. 

By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the 
Jefferson IMedical College, Philadelphia, etc. Handsome royal octavo 
volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- 
graphic plates. Cloth, ^4.00 net ; Sheep or Half Morocco, $5.00 net. 

" A clearly written, comprehensive manual. One which we can commend to students 
as a reliable text-book, written with an evident knowledge of the wants of those entering 
upon the study of this special branch of medical science." — British I^Iedical Journal. 

" A work that will meet the requirements not only of the specialist, but of the general 
practitioner in a rare degree. I am satisfied that unusual success awaits it." — William 
Pepper, M.D.. Professor of the Theory and Practice of Medicitte and Clinical Medicine, 
University of Pennsylvania. 

DORLAND'S DICTIONARY. Third Edition, Revised. 

The American Pocket Medical Dictionary. Containing the Pro- 
nunciation and Definition of all the principal words and phrases, and a 
large number of useful tables. Edited by W. A. Newman Borland, 
ALL). , Assistant Demonstrator of Obstetrics, University of Pennsylvania ; 
Fellow of the American Academy of Medicine. 518 pages ; handsomely 
bound in full leather, limp, with gilt edges and patent index. Price, 
$1.00 net; with thumb index, $1.25 net. 

DORLAND'S OBSTETRICS. 

A Manual of Obstetrics. By W. A. Newman Borland, ALB., 
Assistant Bemonstrator of Obstetrics, L'niversity of Pennsylvania; 
Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 
163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net, 

" By far the best book on this subject that has ever come to our notice." — American 
Medical Review. 

" It has rarely been our duty to review a book which has given us more pleasure in its 
perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, 
a gold mine of practical, concise thoughts." — Af/terican Medico- Sui-gical Bulletin. 



Medical Publications of W. B. Saunders & Co. 13 

PROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST. 

Laboratory Guide for the Bacteriologist. By Langdon Froth- 
iNGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, 
Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. 

" It is a convenient and useful little work, and will more than repay the outlay neces- 
sary for its purchase in the saving of time which would otherwise be consumed in looking 
up the various points of technique so clearly and concisely laid down in its pages. " — ^;«f?'2- 
can Medico- Surgical Bulletin. 

QARRIGUES' DISEASES OF WOMEN. Third Edition, Revised. 
Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- 
fessor of Gynecology in the New York School of Clinical Medicine ; 
Gynecologist to St. Mark's Hospital and to the German Dispensary, 
New York City, etc. Handsome octavo volume of 783 pages, illus- 
trated by 367 engravings and colored plates. Cloth, $4.00 net; 
Sheep or Half Morocco, $5.00 net. 

" One of the best text-books for students and practitioners which has been published in 
the English language ; it is condensed, clear, and comprehensive. The profound learning 
and great clinical experience of the distinguished author find expression in this book in a 
most attractive and instructive form. Young practitioners to whom experienced consultants 
may not be available will find in this book invaluable counsel and help." — Thad. A. 
Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. 

GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. 
Essentials of Diseases of the Ear. By E. B. Gleason, S.B., 
M.D., Clinical Professor of Otology, Medico-Chirurgical College, 
Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- 
ment of the Northern Dispensary, Philadelphia. 20S pages, with 114 
illustrations. Cloth, $1.00 net; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Compe7ids, page 23.] 

" It is just the book to put into the hands of a student, and cannot fail to give him a 
useful introduction to ear-affections ; while the style of question and answer which is adopted 
throughout the book is, we believe, the best method of impressing facts permanently on the 
mind." — Liverpool Medico-Chirurgical Jotcntal. 

GOULD AND PYLE'S CURIOSITIES OF MEDICINE. 

Anomalies and Curiosities of Medicine. By George M. Gould, 
M.D., and Walter L. Pyle, M.D. An encyclopedic collection of 
rare and e.xtraordinary cases and of the most striking instances of 
abnormality in all branches of Medicine and Surgery, derived from an 
exhaustive research of medical literature from its origin to the present 
day, abstracted, classified, annotated, and indexed. Handsome im- 
perial octavo volume of 968 pages, with 295 engravings in the te.xt, 
and 12 full-page plates. 

POPULAR EDITION: Cloth, $3.00 net .• Half Morocco, $4.00 net. 

" One of the most valuable contributions ever made to medical literature. It is, so far 
as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for 
the medical profession has this volume value: it will serve as a book of reference for all who 
are -interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical 
Journal. 

"This is certainly a most remarkable and interesting volume. It stands alone among 
medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in 
medical literature. It is a book full of revelations from its first to its last page, and cannot 
but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 



14 Medical Publications of W. B. Saunders & Co. 

GRAFSTROM'S MECHANO=THERAPY. 

A Text=Book of Mechano=Therapy (Massage and Medical Qym= 
nasties j. By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in 
the Royal Swedish Army ; late House Physician City Hospital, Black- 
well's Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net. 

GRIFFITH ON THE BABY. Second Edition, Revised. 

The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- 
cal Professor of Diseases of Children, University of Pennsylvania; 
Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 
pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net. 

" The best book for the use of the young mother with which we are acquainted. . . . 
There are very few general practitioners who could not read the book through with advan- 
tage." — Archives of Pediatrics. 

"The whole book is characterized by rare good sense, and is evidently written by a 
master hand. It can be read witli benefit not only by mothers but by medical students and 
by any practitioners who have not had large opportunities for observing children." — Ameri- 
can Journal of Obstetrics. 

GRIFFITH'S WEIGHT CHART. 

Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., 
Clinical Professor of Diseases of Children in the University of Penn- 
sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. 

GROSS, SAMUEL D., AUTOBIOGRAPHY OF. 

Autobiography of Samuel D. Gross, M. D., Emeritus Professor of 
Surgery in the Jefferson Medical College, Philadelphia, with Remi- 
niscences of His Times and Contemporaries. Edited by his Sons, 
Samuel W. Gross, M.D., LL.D., and A. Haller Gross, A.M. Pre- 
ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D. 
Two handsome volumes, over 400 pages each, demy octavo, gilt tops, 
with Frontispiece on steel. Price per volume, $2.50 net. 

HAMPTON'S NURSING. Second Edition, Revised and Enlarged. 
Nursing: Its Principles and Practice. By Isabel Adams Hamp- 
ton, Graduate of the New York Training School for Nurses attached 
to Bellevue Hospital ; late Superintendent of Nurses and Principal of 
the Training School for Nurses, Johns Hopkins Hospital, Baltimore, 
Md. 12 mo, 512 pages, illustrated. Cloth, ^2.00 net. 

" Seldom have we perused a book upon the subject that has given us so much pleasure 
as the one before us. We would strongly urge upon the members of our own profession the 
need of a book like this, for it will enable each of us to become a training school in him- 
self." — Ontario Aledical Journal. 

HARE'S PHYSIOLOGY. Fourth Edition, Revised. 

Essentials of Physiology. By H. A. Hare, M.D., Professor of 
Therapeutics and Materia Medica in the Jefferson Medical College of 
Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Sauiiders" Question- Compends, page 23.] 

"The best condensation of physiological knowledge we have yet seen." — Medical 
Record, New York. 



Medical Publications of W. B. Saunders & Co. 15 

HART'S DIET IN SICKNESS AND IN HEALTH. 

Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly 
Student of the Faculty of Medicine of Paris and of the London School 
of Medicine for Women ; with an Introduction by Sir Henry 
Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, ^1.50 net. 

" We recommend it cordially to the attention of all practitioners ; both to them and to 
their patients it may be of the greatest service." — New Yo7-k Medical Journal. 

HAYNES' ANATOMY. 

A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct 
Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- 
ment of the New York University, etc. 680 pages, illustrated with 42 
diagrams in the text, and 134 full-page half-tone illustrations from 
original photographs of the author's dissections. Cloth, ^2.50 net. 

" This book is the work of a practical instructor — one who knows by experience the 
requirements of the average student, and is able to meet these i-equirements in a very satis- 
factory way. The book is one that can be commended." — Medical Record, New York. 

HEISLER'S EMBRYOLOGY. 

A Text=Book of Embryology. By John C. Heisler, M.D., Pro- 
fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. Oc- 
tavo volume of 405 pages, handsomely illustrated. Cloth, ^2.50 net. 

HIRST'S OBSTETRICS. Second Edition. 

A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome 
octavo volume of 848 pages, with 618 illustrations, and 7 colored 
plates. Cloth, $5.00 net; Sheep or Half Morocco, ^6.00 net. 

" The illustrations are numerous and are works of art, many of them appearing for the 
first time. The arrangement of the subject-matter, the foot-notes, and index are beyond 
criticism. As a true model of what a modern text-book on obstetrics should be, we feel 
justified in affirming that Dr. Hirst's book is without a rival." — Neiu York Medical Record. 

HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL 
DISEASES. Second Edition, Revised and Enlarged. 
Syphilis and the Venereal Diseases. By James Nevins Hyde, 
M. D., Professor of Skin and Venereal Diseases, and Frank H. Mont- 
gomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases 
in Rush Medical College, Chicago, 111. Octavo, nearly 600 pages, with 
14 beautiful lithographic plates and numerous illustrations. 

" We can commend this manual to the student as a help to him in his study of venereal 
diseases. ' ' — Liverpool Medico- Chirurgical Journal. 

"The best student's manual which has appeared on the subject." — St. Louis Medical 
and Surgical Journal. 

INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. 
By American and British authors. Edited by J. Collins Warren, 
M.D., LL.D., Professor of Surgery, Harvard Medical School, Boston; 
and A. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur- 
gery and Teacher of Operative Surgery, Middlesex Hospital Medical 
School, London, Eng. Vol. I. General Siirs^ery. — Handsome octavo, 
947 pages, with 458 beautiful illustrations and 9 lithographic plates. 
Vol. II. Special 07- Re,^ioiiaI Suri:;cry. — Handsome octavo, 1072 pages, 
with 471 beautiful illustrations and 8 lithographic plates. Prices per 
volume: Cloth, $5.00 net; Half Morocco, $6.00 net. 



16 Medical Publications of W. B. Saunders & Co. 

JACKSON'S DISEASES OF THE EYE. 

A Manual of Diseases of the Eye. By Edward Jackson, A.M., 
M.D., sometime Professor of Diseases of the Eye in the Philadelphia 
Polyclinic and College for Graduates in Medicine. i2mo volume of 
535 P^g^^j with 17S beautiful illustrations, mostly from drawings by the 
author. Cloth, 5^-50 net. 

JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND 
THROAT. Second Edition, Revised. 
Essentials of Refraction and Diseases of the Eye. By Edward 
Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- 
delphia Polyclinic and College for Graduates in Medicine; and — 
Essentials of Diseases of the Nose and Throat. By E. Bald- 
win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and 
Ear Department of the Northern Dispensary of Philadelphia. Two 
volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, 
§1.00 net; interleaved for notes, $1.25 net. 

[See Saunders' Question-Cojnpends, page 22.] 

" Of great value to the beginner in these branches. The authors are both capable men, 
and know what a student most needs." — Medical Record, New York. 

KEATINQ'S DICTIONARY. Second Edition, Revised. 

A New Pronouncing Dictionary of Medicine, with Phonetic 
Pronunciation, Accentuation, Etymology, etc. By John M. 
Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- 
delphia, and Henry Hamilton ; with the collaboration of J. Chal- 
mers DaCosta, M.D., and Frederick A. Packard, M.D. With an 
Appendix contain! g Tables of Bacilli, Micrococci, Leucomaines, 
Ptomaines, etc. One volume of over 800 pages. Prices, with Ready- 
Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 
net. Without Patent Index : Cloth, $4.00 net ; Sheep or Half Morocco, 
$5.00 net. 

"I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- 
ing it to my classes." — Henry M. Lyman, M. D., Professor of the Principles and Practice 
if Medicine, Rush Medical College, Chicago, III. 

KEATING'S LIFE INSURANCE. 

How to Examine for Life Insurance. By John M. Keating, 
M. D., Fellow of the College of Physicians of Philadelphia; Vice- 
President of the American Paediatric Society; Ex- President of the 
Association of Life Insurance Medical Directors. Royal octavo, 211 
pages ; with two large half-tone illustrations, and a plate prepared by 
Dr. McClellan from special dissections ; also, numerous other illustra- 
tions. Cloth, $2.00 net. 

KEEN'S OPERATION BLANK. Second Edition, Revised Form. 
An Operation Bl^nk, with Lists of Instruments, etc., Required 
in Various Operations. Prepared by W. W. Keen, M.D., LL.D., 
Professor of the Principles of Surgery in Jefferson Medical College, 
Philadelphia. Price per pad, blanks for fifty operations, 50 cents net. 



Medical Publications of W. B. Saunders d^ Co. 17 

KEEN ON THE SURGERY OF TYPHOID FEVER. 

The Surgical Complications and Sequels of Typhoid Fever. 

By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- 
gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; 
Corresponding Member of the Soci^te de Chirurgie, Paris ; Honorary 
Member of the Societe Beige de Chirurgie, etc. Octavo volume of 
386 pages, illustrated. Cloth, $3.00 net. 

" This is probably the first and only work in the English language that gives the reader 
a clear view of what typhoid fever really is, and what it does and can do to the human 
organism. This book should be in the possession of every medical man in America." — 
American Medico- Surgical Bulletin. 

KYLE ON THE NOSE AND THROAT. 

Diseases of the Nose and Throat. By D. Braden Kyle, M.D., 
Clinical Professor of Laryngology and Rhinology, Jefferson Medical 
College, Philadelphia; Consulting Laryngologist, Rhinologist, and 
Otologist, St. Agnes' Hospital. Handsome octavo volume of about 
630 pages, with over 150 illustrations and 6 lithographic plates. Price, 
Cloth, ^4.00 net; Half Morocco, ^5.00 net. 

LAINE'S TEMPERATURE CHART. 

Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 131^ 
inches. A conveniently arranged Chart for recording Temperature, 
with columns for daily amounts of Urinary and Fecal Excretions, 
Food, Remarks, etc. On the back of each chart is given in full the 
method of Brand in the treatment of Typhoid Fever. Price, per pad 
of 25 charts, 50 cents net. 

" To the busy practitioner this chart will be found of great value in fever cases, and 
especially for cases of typhoid." — Itidian Lancet, Calcutta. 

LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY. 

The Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes- 
sor in the University of Strassburg, and Ff.lix Klemperer, Privat docent 
in the University of Strassburg. Translated and edited by Augustus 
A. EsHNER, M.D., Professor of Clinical Medicine in the Philadelphia 
Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, $2,50 net. 

LOCKWOOD'S PRACTICE OF MEDICINE. 

A Manual of the Practice of Medicine. By George Roe Lock- 
WOOD, M.D., Professor of Practice in the Woman's Medical College 
of the New York Infirmary, etc. 935 pages, with 75 illustrations in 
the text, and 22 full-page plates. Cloth, ^2.50 net. 

" Gives in a most concise manner the points essential to treatment usually enumeratec 
in the most elaborate works." — Massachusetts Medical Journal. 

LONG'S SYLLABUS OF GYNECOLOGY. 

A Syllabus of Gynecology, arranged in Conformity with "An 
American Text=Book of Gynecology." l!y J. \\. Long, M.D., 
Professor of Diseases of Women and Children, Medical College of 
Virginia, etc. Cloth, interleaved, $1.00 net. 

" The book is certainly an admirable resume of what every gynecological student and 
practitioner should know, and will prove of value not only to those who have the ' Americar 
Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 



18 Medical Publications of W. B. Saunders & Co, 



MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. 

Surgical Diagnosis and Treatment. By J. W, Macdonald, M.D. 
Edin., F.R.C.S., Edin., Professor of the Practice of Surgery and of 
Clinical Surgery in Hamline University ; Visiting Surgeon to St. 
Barnabas' Hos])ital, Minneapolis, etc. Handsome octavo volume of 
800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, 
$6. CO net. 

" A thorough and complete work on surgical diagnosis and treatment, free from pad- 
ding, full of valuable material, and in accord with the surgical teaching of the day. ' — The 
Medical JVezvs, N'ew York. 

" The work is brimful of just the kind of practical information that is useful alike to 
students and practitioners. It is a pleasure to commend the bock because of its intrinsic 
valuo to the medical practitioner." — Cincinttati Lancet-Clinic 

MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. 

Pathological Technique. A Practical Manual for Laboratory Work 
in Pathology, Bacteriology, and Morbid Anatomy, wich chapters on 
Post-Mortem Technique and the Performance of Autopsies. By Frank 
B. Mallory, A.M., M.D., Assistant Professor of PatholoC'y, Harvard 
University Medical School, Boston; and James K. Wrujht, A.M., 
M.D., Instructor in Pathology, Harvard University Medical School, 
Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, 
$2.50 net. 

" I have been looking forward to the publication of this book, and I am gi.Td to say that 
I find it to be a most useful laboratory and post-mortem guide, full of practical information, 
and w^ell up to date." — William H. Welch, Professor of Pathology, fohns jlopkins Uni- 
versity, Baltimore, Aid. 

MARTIN'S MINOR SURGERY, BANDAGING, AND VEiiNEREAL 
DISEASES. Second Edition, Revised. 
Essentials of Minor Surgery, Bandaging, and Venvireal 
Diseases. By Edward Martin, A.M., M.D., Clinical Professcof 
Genito-Urinary Diseases, University of Pennsylvania, etc. Crown 
octavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; interleaved 
for notes, ^1.25 net. 

[See Saunders' Question- Compends, page 23.] 

"A very practical and systematic study of the subjects, and shows the author's famil- 
iarity with the needs of students." — Therapeutic Gazette. 

MARTIN'S SURGERY. Seventh Edition, Revised. 

Essentials of Surgery. Containing also Venereal Diseases, Surgi- 
cal Landmarks, Minor and Operative Surgery, and a complete de- 
scription, with illustrations, of the Handkerchief and Roller Bandages. 
By Edward Martin, A.M., ALD., Clinical Professor of Genito- 
Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 342 
pages, illustrated. With an Appendix on the preparation of the materials 
used in Antiseptic Surgery, etc., and a chapter on Appendicitis. Cloth, 
$1.00 net; interleaved for notes, $1.25 net 

\?)Qe Saundefs' Question- Compends, page 23.] 

" Contains all necessary essentials of modern surgery in a comparatively small space. 
Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter, 



Medical Publications of W. B. Saunders & Co. 19 

McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- 
vised and Greatly Enlarged. 
Text=Book upon the Pathogenic Bacteria. By Joseph McFar- 
LAND, M. D. , Professor of Pathology and Bacteriology in the Medico- 
Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, 
finely illustrated. Cloth, ^2.50 net. 

" Dr. McFarland has treated the subject in a systematic manner, and has succeeded in 
presenting in a concise and readable form the essentials of bacteriology up to date. Alto- 
gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the 
students of Trinity College."— H. B. Anderson, M.D. , Professor of Pathology and Bac- 
teriology, Trinity Medical College, Toronto. 

MEIGS ON FEEDING IN INFANCY. 

Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound 
in limp cloth, flush edges, 25 cents net. 

"This pamphlet is worth many times over its price to the physician. The author's 
experiments and conclusions are original, and have been the means of doing much good." — ' 
Medical Btdletin. 

MOORE'S ORTHOPEDIC SURGERY. 

A Manual of Orthopedic Surgery. By James E. Moore, M.D., 
Professor of Orthopedics and Adjunct Professor of Clinical Surgery, 
University of Minnesota, College of Medicine and Surgery. Octavo 
volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net. 

" A most attractive work. The illustrations and the care with which the book is adapted 
to the wants of the general practitioner and the student are worthy of great praise." — Chicago 
Medical Recorder. 

"A very demonstrative work, every illustration of which conveys a lesson. The work is 
a most excellent and commendable one, which we can certainly endorse with pleasure." — ■ 
St. Louis Medical and Surgical Journal. 

MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth 
Edition, Revised. 
Essentials of Materia Medica, Therapeutics, and Prescription- 
Writing. By Henry Morris, M.D., late Demonstrator of Thera- 
peutics, Jefferson Medical College, Philadelphia; Fellow of the College 
of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, 
^i.oo net; interleaved for notes, $1.25 net. 

[See Saunders'' Question- Conpends, page 22.] 

"This work, already excellent in the old edition, has been largely improved by revi- 
sion." — American Practitioner and News. 

MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. 
Third Edition, Revised. 
Essentials of the Practice of Medicine. By PIenry Morris, M.D., 
late Demonstrator of Thera|)eutics, Jefferson Medical College, Phila- 
delphia; with an Apt)endix on the Clinical and Microscopic Examina- 
.tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, 
Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- 
tial formulae collected and arranged by Wii>liam M. Powell, M.D. 
Post-octavo, 488 pages. Cloth, $1.50 net. 

[See Saunders^ Question- Compends, page 22.] 

" The teaching is sound, the presentntion graphic ; matter full as can be desired, '^nd 
s'.yle attractive." — American Practitiontr and News. 



20 Medical Publications of W. B. Saunders & Co. 

MORTEN'S NURSE'S DICTIONARY. 

Nurse's Dictionary of Medical Terms and Nursing Treat- 
ment. Containing Definitions of the Principal Medical and Nursing 
Terms and Abbreviations ; of tlie Instruments, Drugs, Diseases, Acci- 
dents, Treatments, Operations, Foods, Appliances, etc. encountered 
in the ward or in the sick-room. By Honnor Morten, author of 
" How to Become a Nurse," etc. i6mo, 140 pages. Cloth, $1.00 net. 

" A handy, compact little volume, containing a large amount of general information, all 
of which is arranged in dictionary or encyclopedic form, thus facilitating quick reference. 
It is certainly of value to those for whose use it is published." — Chicago Clinical Review. 

NANCREDE'S ANATOMY. Sixth Edition, Thoroughly Revised. 
Essentials of Anatomy, including the Anatomy of the Vi.scera. 
By Charles B. Naxcrede, M.D., LL.D., Professor of Surgery and 
of Clinical Surgery in the University of Michigan, Ann Arbor. Crown 
octavo, 420 pages; 151 . illustrations. Based upon Grafs Anatomy. 
Cloth, $1.00 net; interleaved for notes, $1.25 net. 

[See Saiaiders' Question- Coiipends, page 23.] 

" For self-quizzing and keeping fresh in mind the knowledge of anatomy gained at 
school, it would not be easy to speak of it in terms too favorable. " — American Practitioner. 

NANCREDE'S ANATOMY AND DISSECTION. Fourth Edition. 
Essentials of Anatomy and Manual of Practical Dissection. 

By Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of 
Clinical Surgery, University of Michigan, Ann Arbor. Post-octavo ; 
500 pages, with full-page lithographic plates in colors, and nearly 200 
illustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net. 

" It may in many respects be considered an epitome of Gray's popular work on general 
anatomy, at the same time having some distinguishing characteristics ot its own to commend 
u The plates are of more than ordinary excellence, and are of especial value to students 
in their work in the dissecting room." — Joti) nnt of the American Medical Asiociation. 

NANCREDE'S PRINCIPLES OF SURGERY. 

Lectures on the Principles of Surgery. V>\ Chas. B. Nancrede, 
ALD , LL.D., Professor of Surgerv and of Clinical Surgery, Univer- 
sity of Michigan. Ann Arbor. Octavo volume of 398 pages, illustrated. 
Cloth, $2.50 net. 

NORRIS'S SYLLABUS OF OBSTETRICS. Third Edition, Revised. 
Syllabus of Obstetrical Lectures in the Medical Department 
of the University of Pennsylvania. By Richard C. Norkis, 
A.M., ]\LD., Demonstrator of Obstetiics, University of Penns}lvania. 
Crown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net. 

PENROSE'S DISEASES OF WOMEN. Third Edition, Revised. 
A Text=Book of Diseases of Women. By Charles B. Penrose, 
i\LD., Ph.D., Formerly Professor of Gynecology in the University 
of Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia. 
Octavo volume of 531 pages, handsomely illustrated. Cloth, $3.75 net. 
"T shall value very highly the copy of Penrose's 'Diseases of Women' received. 

I have already recommended it to my class as THE BEST book."— Howard A. Kelly. 

Professor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md. 



Medical Publications of W. B. Saunders & Co. 21 

POWELL'S DISEASES OF CHILDREN. Second Edition. 

Essentials of Diseases of Children. By William M. Powell, 
M.D., Attending Physician to the Mercer House for Invalid Women 
at Atlantic City, N. J. ; late Physician to the Clinic for the Diseases of 
Children in the Hospital of the University of Pennsylvania. Crown 
octavo, 222 pages. Cloth, |i.oonet; interleaved for notes, ^1.25 net. 
[See Saunders' Question- Coinpends, page 21.] 

" Contains the gist of all the best works in the department to which it relates."— 
Amet-icajt Practitioner' and Ah-ws. 

PRINQLE'S SKIN DISEASES AND SYPHILITIC AFFECTIONS. 
Pictorial Atlas of Skin Diseases and Syphilitic Affections 
(American Edition). Translation from the French. Edited by 
J. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex 
Hospital, London. Photo-lithochromes from the famous models in 
the Museum of the Saint-Louis Hospital, Paris, with explanatory wood- 
cuts and text. In 12 Parts. Price per Part, $3.00. Complete in 
one volume, Half Morocco binding, ^40.00 net. 

" I strongly recommend this Atlas. The plates are exceedingly well executed, and 
tvill be of great value to all studying dermatology." — Stephen Mackenzie, M.D. 

"The introduction of explanatory wood-cuts in the text is a novel and most important 
feature which greatly furthers the easier understanding of the excellent plates, than which 
nothing, we venture to say, has been seen better in point of correctness, beauty, and general 
merit." — New York Medical Journal. 

PRYOR— PELVIC INFLAMMATIONS. 

The Treatment of Pelvic Inflammations through the Vagina. 

By W. R. Pryor, M.D., Professor of Gynecology in New York Poly- 
clinic. i2mo, 248 pages, handsomely illustrated. Cloth, ^2.00 net. 

" This subject, which has recently been so thoroughly canvassed in high gynecological 
circles, is made available in this volume to the general practitioner and student. Nothing is 
too minute for mention and nothing is taken for granted ; consequently the book is of the utmost 
value. The illustrations and the technique are beyond criticism." — ■Chicago Alcdical Recorder. 

PYE'S BANDAGING. 

Elementary Bandaging and Surgical Dressing. With Direc- 
tions concerning the Immediate Treatment of Cases of Emergency. 
For the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late 
Surgeon to St. Mary's Hospital, London. Small 121110, with over 80 
illustrations. Cloth, flexible covers, 75 cents net. 

" The directions are clear and the illustrations are good." — London Lancet. 
" The author writes well, the diagrams are clear, and the book itself is small and port- 
able, although the paper and type are good." — British Medical Journal. 

RAYMOND'S PHYSIOLOGY. 

A Manual of Physiology. By Joseph H. Raymond, A.M., M.D., 
Professor of Physiology and Hygiene and Lecturer on Gynecology in 
the Long Island College Plospital ; Director of Physiology in the 
Hoagland Laboratory, etc. 382 pages, with 102 illustrations in the 
text, and 4 full-page colored plates. Cloth, $1.25 net. 

" Extremely well gotten up, and the illustrations have been selected with care. The 
text is fully abreast with modern physiology." — British Medical Journal. 




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1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, 

revised and enlarged. 

2. ESSENTIALS OF SURGERY. By Edward Martin, xM- D. Seventh edition, 

revised, with an Appendix and a chapter on Appendicitis. 

3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth 

edition, thoroughly revised and enlarged. 

4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. 

By Lawrence Wolff, M.D. Fifth edition, revised. 

5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth 

edition, revised and enlarged. 

6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. 

Armand Semple, M.D. 

7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- 

SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 

8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, 

M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. 
Third edition, enlarged by some 300 Essential Formulse, selected from eminent 
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10. ESSENTIALS OF QYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth 

edition, revised. 

11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, 

M.D. Fourth edition, revised and enlarged. 

12. ESSENTIALS OF MINOR SURGERY, BANDAGJNG, AND VENEREAL 

DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 

13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 

By C. E. Armand Semple, M.D. 

14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. 

By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 

15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, 

M.D. Second edition. 

16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, 

M.D. Colored " Vogel Scale." (75 cents net.) 

17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner, 

M.D. Second editiijn, thoroughly revised. 

18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre. 

Second edition, revised and enlarged. 

20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition, 

revised. 

21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C. 

Shaw, M.D. Third edition, revised. 

22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D. 

Second edition, revised. 

23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D., 

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24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D. 

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Saunders^ New Series of JVlanuals. 



VOLUMES PUBLISHED. 

PHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology 
and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; 
Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^i. 25 neu 

SURGERY, General and Operative.— By John Chalmers DaCosta, M. D., Pro- 
fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel- 
phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised 
and greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, ^4.00 net; 
Half Morocco, I5.00 net. 

DOSE=BOOK AND MANUAL OF PRESCR1PTI0N=WR1TINQ. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- 
delphia. Illustrated. Cloth, §1.25 net. 

SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and 
to the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net. 

MEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti- 
tutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila- 
delphia. Illustrated. Cloth, ^1.50 net. 

SYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D., 
Professor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D., 
Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College,, 
Chicago. Second edition, thoroughly revised and greatly enlarged. 

PRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of 
Practice in the Woman's Medical College of the New York Infirmary; Instructor in 
Physical Diagnosis in the Medical Department of Columbia College, etc. Illustrated. 
Cloth, ^2.50 net. 

MANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of 
Anatomy and Demonstrator of Anatomy, Medical Department of the Ne'v YorK 
University, etc. Beautifully illustrated. Cloth, ^2.50 net. 

MANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant 
Demonstrator of Obstetrics, University of Pennsylvania ; Chief of Gynecological Dis- 
pensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, ^2.50 net. 

DISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to 
Middlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E. 
Giles, M.D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, 
London. Flandsomely illustrated. Cloth, ;^2.50 net. 



VOLUMES IN PREPARATION. 

NERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous 
Diseases, Medico-Chirurgical College, Philadelphia ; Pathologist to the Orthopredic 
Hospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph 
Hospital, etc. 

*** There will be published in the same series, at short intervals, carefully-prepared workf 
on various subjects by prominent specialists. 



Pamphlet containing specimen pages, etc. sent free upon application. 



2S Medical Publications of W. B. Saunders iSr Co. 



SAUNDBY'S RENAL AND URINARY DISEASES. 

Lectures on Renal and Urinary Diseases. By Robert Saundby, 
M.D. Edin., Fellow of the Royal College of Physicians, London, and 
of the Royal Medico-Chirurgical Society ; Physician to the General 
Hospital ; Consulting Physician to the Eye Hospitax and to the Hos- 
pital for Diseases of Women; Professor of Medicine in Mason College, 
Birmingham, etc. Octavo volume of 434 pages, with numerous illus- 
trations and 4 colored plates. Cloth, $2.50 net. 

" The volume makes a favorable impression at once. The style is clear and succinct. 
We cannot find any part of the subject in which the views expressed are not carefully thought 
out and fortified by evidence drawn from the most recent sources. The book may be cordially 
recommended." — British ^ledical Journal, 

5AUNDERS' MEDICAL HAND=ATLA5ES. 

For full description of this series, with list of volumes and prices, see 
page 2. 

" Lehmann Medicinische Handatlanten belong lo that class of books that are too good 
to be appropriated by any one nation." — yournal of Eye, Ear, and Throat Diseases. 

'• The appearance of these works marks a new era in illustrated English medical 
works." — The CaJiadian Practitioner. 

SAUNDERS' POCKET MEDICAL FORMULARY. Sixtli Edition, 
Revised. 

By William M. Powell, M.D., Attending Physician to the Mercer 
House for Invalid Women at Atlantic City, N. J. Containing 1800 
formulae selected from the best-known authorities. With an Appen- 
dix containing Posological Table, Formulae and Doses for Hypo- 
dermic Medication, Poisons and their Antidotes, Diameters of the 
Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various 
Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment 
of Asphyxia from Drowning, Surgical Remembrancer, Tables of 
Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- 
somely bound in flexible morocco, with side index, wallet, and flap. 
^1.75 net. 

" This little book, that can be conveniently carried in the pocket, contains an immense 
amount of material. It is ver\- useful, and, as the name of the author of each prescription 
is given, is unusually reliable." — Medical Record, New York. 

SAYRE'S PHARMACY. Second Edition, Revised. 

Essentials of the Practice of Pharmacy. By Lucius E. Sayre, 
M.D., Professor of Pharmacy and Materia Medica in the University of 
Kansas. Crown octavo, 200 pages. Cloth, $1.00 net; interleavef for 
notes, ^1.25 net. 

[See Saunders' Question- CoJiipends, page 21.] 

" The topics are treated in a simple, practical manner, and the work forms a very usefuj 
Student's manual." — Boston Medical and Surgical Journal. 

SCUDDER'S FRACTURES. 

The Treatment of Fractures. By Chas. L. Scudder, M.D., As- 
sistant in Clinical and Operative Surgery, Harvard Medical School. 
Octavo, 433 pages, with nearly 600 original illustrations. Cloth, §4.50 



Medical Publications of W. B. Saunders & Co. 11 

SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. 
Essentials of Legal Medicine, Toxicology, and Hygiene. By 

C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., 
Physician to the Northeastern Hospital for Children, Hackney, etc. 
Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saimders Question- Compends, page 21.] 

" No general practitioner or student can afford to be without this valuable work. The 
subjects are dealt with by a masterly hand." — London Hospital Gazette. 

SEMPLE'S PATHOLOGY AND MORBID ANATOMY. 

Essentials of Pathology and Morbid Anatomy. By C. E. 

Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to 
the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 
pages; illustrated. Cloth, $1.00 net; interleaved for notes, $1.25 n-t. 
[See Saunders'' Question- Cojnpends, page 21.] 

" Should take its place among the standard volumes on the bookshelf of both student 
and practitioner." — Lotidon Hospital Gazette. 

SENN'S GENITO=URINARY TUBERCULOSIS. 

Tuberculosis of the Genito=Urinary Organs, Male and Femaleo 

By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of 
Surgery and of Clinical Surgery, Rush Medical College, Chicago. 
Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net. 

" An important book upon an important subject, and written by a man of mature judg- 
ment and wide experience. The author has given us an instructive book upon one of the 
most important subjects of the day." — Clinical Reporter. 

" A work which adds another to the many obligations the profession owes the talented 
author." — Chicago Medical Recorder. 

SENN'S SYLLABUS OF SURGERY. 

A Syllabus of Lectures on the Practice of Surgery, arranged 
in conformity with " An American Text=Book of Surgery." By 

Nicholas Seen, M. D., Ph.D., Professor of the Practice of Surgery and 
of Clinical Surgery, Rush Medical College, Chicago. Cloth, ^1.50 net. 

" This syllabus will be found of service by the teacher as well as the student, the work 
being superbly done. There is no praise too high for it. No surgeon should be without 
it." — New York Medical Times. 

SENN'S TUMORS. Second Edition, Revised. 

Pathology and Surgical Treatment of Tumors. By N. Senn, 

M.D, Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, 
Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; 
Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. 
Joseph's Hospital, Chicago. Second Edition, T]ioroui:;hly Revised. Oc- 
tavo volume of 718 pages, with 478 illustrations, including 12 full-page 
plates in colors. Prices: Cloth, ^5.00 net; Half Morocco, ;$6.oo net. 

" The most exhaustive of any recent book in Engiish on this subject. It is well illus- 
trated, and will doubtless remain as the principal monograph on the subject in our language 
for some years. The book is handsomely illustrated and printed, and the author has given a 
notable and lasting contribution to surgery." — Jourtial of the At)(erica7i Medical Association. 



28 Medical Publications of W. B. Saunders & Co. 

SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, 
Revised. 
Essentials of Nervous Diseases and Insanity. By John C. 
Shaw. M.D., Clinical Professor of Diseases of the Mind and Nervous 
System, Long Island College Hospital Medical School ; Consulting 
Neurologist to St. Catherine's Hospital and to the Long Island College 
Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, 
$1.00 net; interleaved for notes, $1.25 net. 

[See Saunders' Questioii-Coinpends, page 21.] 

"Clearly and intelligently written." — Boston Medical and Surgical Journal. 
"There is a mass of valuable material crowded into this small compass.' — American 
Medico-Surgical Bulletin. 

STARR'S DIETS FOR INFANTS AND CHILDREN. 

Diets for Infants and Children in Health and in Disease. By 

Louis Starr, M.D., Editor of "An American Text-Book of the 
Diseases of Children." 230 blanks (pocket-book size), perforated 
and neatly bound in flexible morocco. §1.25 net. 

The first series of blanks are prepared for the first seven months of infant life ; each 
Mank indicates the ingredients, but not the quantities, of the food, the latter directions being 
left for the physician. After the seventh month, modifications being less necessary, the diet 
lists are printed in full. Formulae for the preparation of diluents and foods are appended. 

STELWAGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. 
Essentials of Diseases of the Skin. By Henry W. Stelwagon, 
M.D., Clinical Professor of Dermatology in the Jefferson Medical 
College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; 
Physician to the Skin Department of the Howard Hospital, etc. 
Crown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter- 
leaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 
" The best student's manual on skin diseases we have yet seen." — Times and Register. 

STENGEL'S PATHOLOGY. Second Edition. 

A Text=Book of Pathology. By Alfred Stengel, M.D., Professor 
of Clinical Medicine in the University of Pennsylvania ; Physician to 
the Philadelphia Hospital ; Physician to the Children's Hospital, etc. 
Handsome octavo volume of 848 pages, with nearly 400 illustrations, 
many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 
net. 

STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second 
Edition, Revised. 
A Manual of Materia Medica and Therapeutics. By A. A. 

Stevens, A.M., IM.D., Lecturer on Terminology and Instructor in 
Physical Diagnosis in the LTniversity of Pennsylvania ; Professor of 
Pathology in the Woman's Medical College of Pennsylvania. Post- 
octavo, 445 pages. Flexible leather, §2.00 net. 

'•The author has faithfully presented modern therapeutics in a comprehensive work, 
and, while intended particularly for the use of students, it will be found a reliable guide and 
sufficiently comprehensive for the physician in practice." — University Medical Magazine. 



Medical Publications of W. B. Saunders & Co. 29 

5TEVEN5' PRACTICE OF MEDICINE. Fifth Edition, Revised. 
A Manual of the Practice of Medicine. By A. A. Stevens, A. M., 
M. D., Lecturer on Terminology and Instructor in Physical Diagnosis 
in the University of Pennsylvania ; Professor of Pathology in the 
Woman's Medical College of Pennsylvania. Specially intended for 
students preparing for graduation and hospital examinations. Post- 
octavo, 519 pages; illustrated. Flexible leather, ^2.00 net. 

" The frequency with which new editions of this manual are demanded bespeaks its 
popularity. It is an excellent condensation of the essentials of medical practice for the 
student, and maybe found also an excellent reminder for the busy physician." — Buffalo 
Medical Journal. 

STEWART'S PHYSIOLOGY. Third Edition, Revised. 

A Manual of Physiology, with Practical Exercises. For 
Students and Practitioners. By G. N. Stewart, M.A., M.D., 
D.Sc, lately Examiner in Physiology, University of Aberdeen, and 
of the New Museums, Cambridge University ; Professor of Physiology 
in the Western Reserve University, Cleveland, Ohio. Octavo volume 
of 848 pages ; 300 illustrations in the text, and 5 colored plates. 
Cloth, ^3.75 net. 

" It will mate its way by sheer force of merit, and amply deserves to do so. It is one 
of the very best English tesct-books on the subject." — London Lancet. 

' ' Of the many text-books of physiology published, we do not know of one that so 
nearly comes up to the ideal as does Prof Stewart's volume." — British Medical Journal. 

STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. 

Essentials of Medical Electricity. By D. D. Stewart, M.D., 
Demonstrator of Diseases of the Nervous System and Chief of the 
Neurological Clinic in the Jefferson Medical College; and E. S. 
Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- 
strator of Diseases of the Nervous System in the Jefferson Medical 
College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, 
^i.oo net; interleaved for notes, $1.25 net. 

[See Saunders' Question- Compends, page 21.] 

" Throughout the whole brief space at their command the authors show a discriminating 
knowledge of their subject." — Medical News. 

STONEY'S NURSING. Second Edition, Revised. 

Practical Points in Nursing. For Nurses in Private Practice. 

By Emily A. M. Stoney, Graduate of the Training-School for Nurses, 
Lawrence, Mass.; late Superintendent of the Training-School for 
Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated 
with 73 engravings in the text, and 8 colored and half-tone plates. 
Cloth, $1.75 net. 

" There are few books intended for non-professional readers which can be so cordially 
endorsed by a medical journal as can this one." — Therapeutic Gazette. 

" This is a well-written, eminently practical volume, which covers the entire range of 
private nursing as distinguished from hospital nursing, and instructs the nurse how best to 
meet the various emergencies which may arise, and how to prepare everything ordinarily 
needed in the illness of her patient." — .4!>ierican Journal of Obstetrics and Diseases of 
IVowen and Childreti. 

" It is a work that the physician can place in the hands of his private nurses with the 
assurance of benefit." — Ohio Medical Journal. 



30 Medical Publications of W. B. Saunders & Co. 

STONEY'S MATERIA MEDICA FOR NURSES. 

Materia Medica for Nurses. Ey Emily A. M. Stoney, Graduate of 
the Training-School for Nurses, Lawrence, Mass. ; late Superintendent 
of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 
Handsome octavo volume of 306 pages. Cloth, $1.50 net. 

The present book differs from other similar works in several features, all of which are 
intended to render it more practical and generally useful. The general plan of the contents 
jollows the lines laid down in training-schools for nurses, but the book contains much use- 
ful matter not usually included in works of this character, such as Poison-emergencies, 
Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms 
used in Materia Medica, and describing all the latest drugs and remedies, which have been 
generally neglected by other books of the kind. 

SUTTON AND GILES' DISEASES OF WOMEN. 

Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant 
Surgeon to Middlesex- Hospital, and Surgeon to Chelsea Hospital, 
London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., 
Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- 
somely illustrated. Cloth, $2.50 net. 

"The text has been carefully prepared. Nothing essential has been omitted, and its 
teachings are those recommended by the leading authorities of the day." — Journal of the 
American Medical Association. 

THOMAS'S DIET LISTS. Second Edition, Revised. 

Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, 
M.D., Visiting Physician to the Home for Friendless Women and 
Children and to the Newsboys' Home ; Assistant Visiting Physician to 
the Kings County Hospital. Cloth, $1.25 net. Send for sample sheet. 

THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITINQ. 

Dose=Book and Manual of Prescription=Writing. By E. Q. 

Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical 
College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. 

"Full of practical suggestions; will take its place in the front rank of works of this 
sort." — Medical Record, New \'ork. 

VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. 
Diseases of the Stomach. By William W. Van Valzah, M.D.,. 
Professor of General Medicine and Diseases of the Digestive System 
and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., 
Adjunct Professor of General Medicine and Diseases of the Digestive 
System and the Blood, New York Polyclinic. Octavo volume of 674 
pages, illustrated. Cloth, $3.50 net. 

" Its chief claim lies in its clearness and general adaptability to the practical needs of 
the general practitioner or student. In these relations it is probably the best of the recent 
special works on diseases of the stomach." — Chicago Clinical Review. 

VECKi'S SEXUAL UMPOTENCE. 

The Pathology and Treatment of Sexual Impotence. By Victor 
G. Vecki, M D. From the second German edition, revised and en- 
larged. Demi-octavo, 291 pages. Cloth, $2.00 net. 

The subject of impotence has seldom been treated in this country in the truly scientific 
sr-'Ht that it deserves. Dr. Vecki's work has long been favorably known, and the German 
tx)ok has received the highest consideration. This edition is more than a mere translation, 
k)r, although based on the German edition, it has been entirely rewritten in English. 



3Iedical Piihlications of W. B. Saunders & Co. 31 

V^IERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. 
Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- 
cine at the University of Heidelberg. Translated, with additions, 
from the fifth enlarged German edition, with the author's permission, 
by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume 
of 603 pages; 194 fine wood-cuts in text, many of them in colors. 
Cloth, ^4.00 net; Sheep or Half Morocco, $5.00 net. 

" Rarely is a book published with which a reviewer can find so little fault as with the 
volume before us. Each particular item in the consideration of an organ or apparatus, which 
is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing 
seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and 
nervous system are especially full and valuable. The reviewer would repeat that the book is 
one of the best — probably tAe best — which has fallen into his hands." — University Medicai 



WATSON'S HANDBOOK FOR NURSES. 

A Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri- 
can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer 
on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages, 

73 illustrations. Cloth, ^1.50 net. 

WARREN'S SURGICAL PATHOLOGY. Second Edition. 

Surgical Pathology and Therapeutics. By John Collins Warren, 
M.D., LL.D., Professor of Surgery, Harvard Medical School. Hand- 
some octavo, 832 pages ; 136 relief and lithographic illustrations, 2)Z i^"^ 
colors ; with an Appendix on Scientific Aids to Surgical Diagnosis, and 
a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half 
Morocco, ^6.00 net. 

"A most striking and very excellent feature of this book is its illustrations. Without 
exception, from the point of accuracy and artistic merit, they are the best ever seen in a work 
of this kind. Many of those representing microscopic pictures are so perfect in their coloring 
and detail as almost to give the beholder the impression that he is looking down the barrel 
of a microscope at a well-mounted section." — Annals of Surgery. 

WOLFF ON EXAMINATION OF URINE. 

Essentials of Examination of Urine. By Lawrence Wolff, M.D., 
Demonstrator of Chemistry, Jefferson Medical College, Philadelphia' 
etc. Colored (Vogel) urine scale and numerous illustrations. Crown 
octavo. Cloth, 75 cents net. 

[See Saunders' Question- Compends, page 21.] 
" A very good work of its kind— very well suited to its purpose."— 7z'w« and Register. 

WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. 

Essentials of Medical Chemistry, Organic and Inorganic. 

Containing also Questions on Medical Physics, Chemical Physiology, 
Analytical Processes, Urinalysis, and Toxicology. By Lawrence 
Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, 
Philadelphia, etc. Crown octavo, 222 pages. Cloth, ^i.oo net; inter- 
leaved for notes, gi.25 net. 

[See Saunders' Question- Co7npcnds, page 21.] 

•'The scope of this work is certainly equal to that of the best course of lectures on 
Medical Chemistiy. " — Fhannaceutical Era. 



CLASSIFIED LIST 

OF THE 

Medical Publications 

OF 

W. B. SAUNDERS & COMPANY, 

925 Walnut Street, Philadelphia. 



ANATOMY, EMBRYOLOGY, 
HISTOLOGY. 

Clarkson — A Text-Book of Histology, 1 1 

Haynes — A Manual of Anatomy, . . . 15 

Heisler — A Text- Book of Embryology, 15 

Nancrede — Essentials of Anatomy, . . 20 
Nancrede — Essentials of Anatomy and 

Manual of Practical Dissection, ... 20 

Sample — Essentials of Pathology, . . 27 

BACTERIOLOGY. 

Ball — Essentials of Bacteriology, ... 8 
Crookshank — A Text-Book of Bacteri- 
ology, 12 

Frothingham — Laboratory Guide, . . 13 
Levy and Klemperer's Clinical Bacte- 

ric^l'^gy. 17 

Mallory and Wright — Pathological 

Technique, 18 

McFarland — Pathogenic Bacteria, . . ig 

CHARTS, DIET-LISTS, ETC. 

Griffith— Infant's Weight Chart, ... 14 

Hart — Diet in Sickness and in Health, . 15 

Keen — Operation Blank, 17 

Laine — Temperature Chart. . . -17 

Meigs — Feeding in Early Infancy, . . 19 

Starr — Diets for Infants and Children, . 28 

Thomas — Diet-Lists 30 

CHEMISTRY AND PHYSICS. 

Brockway — Essentials of Medical Phys- 
ics, 9 

Wolff — Essentials of Medical Chemistry, 31 

CHILDREN. 

An American Text-Book of Diseases 

of Children, . . 5 

Griffith — Care of the Baby 14 

Griffith — Infant's Weight Chart, ... 14 

Meigs — Feeding in Early Infancy, . . 19 

Powell — Essentials of Dis. of Children, 21 

Starr — Diets for Infants and Children, . 26 ' 

DIAGNOSIS. I 

Cohen and Eshner —Essentials of Di- I 

agnosis, 11 

Corwin — Physical Diagnosis, .... 11 
Macdonald — Surgical Diagnosis and j 

Treatment, 18 j 

Vierordt— Medical Diagnosis, .... 31 1 

DICTIONARIES. 

Borland— Pocket Dictionary, .... 12 j 

Keating — Pronouncing Dictionary, . . 16 

Morten — Nurse's Dictionary, . . . . 20 1 



EYE, EAR, NOSE, AND THROAT. 

An American Text- Book of Diseases 

of the Eye, Ear, Nose, and Throat, . 5 

De Schweinitz — Diseases of the Eye, . 12 

Gleason — Essentials of Dis. of the Ear, 13 

Jackson — Manual of Diseases of Eye, . 16 
Jackson and Gleason — Essentials of 

Diseases of the Eye, Nose, and Throat, 16 

Kyle — Diseases of the Nose and Throat, 1 7 

GENITO=URINARY. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 6 

Hyde and Montgomery — Syphilis and 

the Venereal Diseases, 15 

Martin — Essentials of Mmor Surgery, 

Bandaging, and Venereal Diseases, . 18 
Saundby — Renal and Urinary Diseases, 26 
Senn — Genito-Urinary Tuberculosis, . 27 
Vecki — Sexual Impotence, 30 

GYNECOLOGY. 

American Text- Book of Gynecology, 6 
Cragin — Essentials of Gynecology, . . II 
Garrigues — Diseases of Women, ... 13 
Long — Syllabus of Gynecology, ... 17 
Penrose— Diseases of Women, .... 20 
Pryor — Pelvic Inflammations, • • • ■ 34 
Sutton and Giles — Diseases of Women, 30 

MATERIA MEDICA, PHARMACOL- 
OGY, AND THERAPEUTICS. 

An American Text-Book of Applied 

Therapeutics 5 

Butler — Text-Book of Materia Medica, 

Therapeutics and Pharmacology, ... 10 
Cerna — Notes on the Newer Remedies, 10 
Griffin — Materia Med. and Therapeutics, 14 
Morris— Essentials of Materia Medica 

and Therapeutics, . . 19 

Saunders' Pocket Medical Formulary, 26 
Sayre— Essentials of Pharmacy, ... 26 
Stevens — Essentials of Materia Medica 

and Therapeutics, 28 

Stoney — Materia Medica for Nurses, . . 30 
Thornton — Dose- Book and Manual of 

Prescription-Writing, 30 

MEDICAL JURISPRUDENCE AND 
TOXICOLOGY. 

Chapman — Medical Jurisprudence and 
Toxicology, ... .... 10 

Sample — Essentials of Legal Medicine, 
Toxicology, and Hygiene, 27 



Medical Publications of W. B. Saunders & Co. 33 



NERVOUS AND MENTAL 
DISEASES, ETC. 

Burr — Nervous Diseases, 

Chapin — Compendium of Insanity, . . 
Church and Peterson — Nervous and 

Mental Diseases, 

Shaw — Essentials of Nervous Diseases 

and Insanity, 

NURSING. 

Griffith — The Care of the Baby, . . . 

Hampton — Nursing, . 

Hart — Diet in Sickness and in Health, 
Meigs — Feeding in Early Infancy, . . 

Morten — Nurse's Dictionary 

Stoney — Materia Medica for Nurses, . . 
Stoney — Practical Points in Nursing, . 
Watson — Handbook for Nurses, . . . 

OBSTETRICS. 

An American Text-Book of Obstetrics, 
Ashton — Essentials of Obstetrics, 
Boisliniere — Obstetric Accidents 
Dorland — Manual of Obstetrics, 
Hirst — Text-Book of Obstetrics, 
Norris — Syllabus of Obstetrics, . 

PATHOLOGY. 

An American Text-Book of Pathology, 

Mallory and Wright — Pathological 
Technique, 

Semple — Essentials of Pathology and 
Morbid Anatomy, 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 

Stengel— Text-Book of Pathology, . . 

M^arren — Surgical Pathology and Thera- 
peutics, 

PHYSIOLOGY. 

An American Text-Book of Physi- 
ology, 

Hare — Essentials of Physiology, . . . 
Raymond — Manual of Physiology, . . 
Stewart — Manual of Physiology, . . . 

PRACTICE OF MEDICINE. 

An American Text-Book of the The- 
ory and Practice of Medicine, .... 

An American Year-Book of Medicine 
and Surgery, 

Anders — Text-Book of the Practice of 
Medicine, 

Lockwood — Manual of the Practice of 
Medicine, 

Morris — Essentials of the Practice of 
Medicine, 

Stevens — Manual of the Practice of 
Medicine, 

SKIN AND VENEREAL. 

An American Text-Book of Genito- 
urinary and Skin Diseases, 

Hyde and Montgomery — Syphilis and 
the Venereal Diseases, 



Martin — Essentials of Minor Surgery, 
Bandaging, and Venereal Diseases, . 

Pringle— Pictorial Atlas of Skin Dis- 
eases and Syphilitic Affections, . . 

Stelwagon— Essentials of Diseases of 



the Skin, 



SURGERY. 

An American Text-Book of Surgery, 7 
An American Year-Book of Medicine 

and Surgery, 8 

Beck — Fractures, g 

Beck — Manual of Surgical Asepsis, . . 9 
DaCosta — Manual of Surgery, . ... 12 
International Text-Book of Surgery, . 15 

Keen — Operation Blank, 17 

Keen — The Surgical Complications and 

Sequels of Typhoid Fever, 17 

Macdonald — Surgical Diagnosis and 

Treatment, 18 

Martin — Essentials of Minor Surgery, 

Bandaging, and Venereal Diseases, . 18 
Martin — Essentials of Surgery, .... 18 

Moore — Orthopedic Surgery, ig 

Nancrede — Principles of Surgery, . . 20 
Pye — Bandaging and Surgical Dressing, 21 
Scudder — Treatment of Fractures, . . 26 
Senn — Genito-Urinary Tuberculosis, . 27 

Senn — Syllabus of Surgery, 27 

Senn — Pathology and Surgical Treat- 
ment of Tumors, 27 

Warren — Surgical Pathology and Ther- 
apeutics, 2 1 



URINE AND URINARY DISEASES. 

Saundby — Renal and Urinary Diseases, 26 
Wolffs Essentials of Examination of 
Urine, 31 



MISCELLANEOUS. 

Abbott — Hygiene of Transmissible Dis- 
eases, 8 

Bastin — Laboratory Exercises in Bot- 
any, 9 

Gould and Pyle — Anomalies and Curi- 
osities of Medicine, 13 

Grafstrom — Massage, 14 

Keating — How to Examine for Lite 

Insurance, - • o 16 

Rowland and Hedley — Archives of 

the Roentgen Ray, 21 

Saunders' Medical Hand- Atlases, .2, 3, 4 
Saunders' New Series of Manuals, 24, 25 
Saunders' Pocket Medical Formulary, 26 
Saunders' Question-Compends, . . 22, 23 
Senn — Pathology and Surgical Treat- 
ment of Tumors, 27 

Stewart and Lawrance — Essentials of 

Medical Electricity, 29 

Thornton — Dose-Book and Manual of 

Prescription-Writing, . 30 

Van Valzah and Nisbet— Diseases of 
the Stomach, 3° 



BOOKS JUST ISSUED. 

THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY. 

For Students and Practitioners. A Complete Dictionary of the Terms used in Medi- 
cine and tlie Allied Sciences, with a large number of Valuable Tables and Numerous 
Handsome Illustrations. Edited by W. A. Newman Borland, M. D., Editor of the 
American Pocket Medical Dictionary. Handsome large octavo, 8oo pages, bound in 
full limp leather, and printed on thin paper of the finest quality, forming a handy 
volume, only I '4.' inches thick. 

This is an entirely new and unique work, intended to meet the need of practitioners and students for a 
complete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of 
matter in a minimum space and at the lowest possible cost. It contains double the material in the ordinary 
students' dictionary, and yet, by the use of a clear, condensed type and thin paper of the finest quality, is only 
i'/{ inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want 
to keep on his desk for constant reference. The book makes a special feature of the newer words, and 
defines hundreds of important terms not to be found in any other dictionary. It is especially full in the 
matter of tables, containing more than a hundred of great practical value. A new feature is the inclusion 
of numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book. 
These have been chosen with great care and add infinitely to the value of the work. The book will appeal 
to both practitioners and students, since, besides a complete vocabulary, it gives to the more important 
subjects extended consideration of an encyclopedic character. 

BOHM, DAVIDOFF, AND HUBER'S HISTOLOGY. 

A Text=Book of Human Histology. Including Microscopic Technic. By Dr. 
A. A. BiiHM and Dr. M. von Davidoff, of Munich, and G. C. Huber, M. D., 
Junior Professor of Anatomy and Histology, University of Michigan. 

FRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND EAR. 

Rhinology, Laryngology, and Otology in their Relations to General 
Medicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by 
H. HoLisROOK CuR'iis, M. D., Consulting Surgeon to the New York Nose and Throat 
Hospital. 

LEROY'S HISTOLOGY. 

The Essentials of Histology. By l.ouis Lerov, M.D., Professor of Histology 
and Pathology, Vanderbilt University, Nashville, Tennessee. 

OQDEN ON THE URINE. 

Clinical Examination of the Urine. By J. Bergen Ogden, M. D., Assistant 
in Chemistry, Harvard Medical School. Handsome octavo volume of over 408 pages, 
with 54 illustrations and 1 1 full-page plates, many in colors. 

PYLE'S PERSONAL HYGIENE. 

A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Assist- 
ant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages, 
fully illustrated. 

SALINGER AND KALTEYER'S MODERN MEDICINE. 

Modern Medicine. By Julius L. SAT.ixr.ER, M. D., Demonstrator of Clinical 
Medicine, Jefferson Medical College, and F. J. Kaltkyer, M. D., Assistant Demon- 
strator of Clinical Medicine, Jefferson Medical College. Handsome octavo volume of 
over 800 pages, fully illustrated. 

STONEY'S SURGICAL TECHNIC FOR NURSES. 

Surgical Technic for Nurses. By Emily A. M. Stoney, late Superintendent 
of tlie Training-School for Nurses, Carney Hospital, South Boston, Massachusetts. 



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